Paravalvular or paraprosthetic leak (PVL) is a complication associated with the surgical/transcatheter implantation of a prosthetic heart valve, more commonly a mechanical than a bioprosthetic valve. Transthoracic echocardiography (TTE) is the most important diagnostic modality for prosthetic valve function/dysfunction. However, TTE often cannot differentiate the PVL from prosthetic regurgitation. Transesophageal echocardiography (TEE) is the modality of choice which is also able to detect small, nonsignificant jets.
We present a case of 78-year-old male who had undergone mitral valve replacement with Epic St. Jude tissue valve 3 years back and now presented to our hospital with NYHA class III dyspnea since few months prior to admission. It was associated with cough with mucoid expectoration along with orthopnea. TTE revealed moderate PAH with increased gradient across bioprosthetic mitral valve with suspicion of peravalvular leak (Fig. 1). Three-dimensional (3D) volume rendering image analysis after cropping suggested oval perivalvular area of leakage which was confirmed with the help of 3D color rendering (Fig. 2). It showed early separation of perivalvular leak from paravalvular area.
The majority of PVL are crescent, oval or roundish-shaped and their track can be parallel, perpendicular or serpiginous. Incidence of PVL, including small nonsignificant jets, is estimated to be as high as 20%.1 TEE is more useful than TTE in evaluating the shape of paravalvular defect. It may also help in assessing eccentric jets and differentiating between single and multiple jets. Major progress in TEE in the area of PVL imaging has been 3D reconstruction.2 A semiquantitative assessment of the size of PVL may be made by measurement of the ratio of total sewing ring circumference to the length of suture dehiscence (>10%: Mild, 10-20%: Moderate, >20%: Severe, >40%: Instability of the prosthetic valve).3
The TEE, especially if 3D volume rendering is used along with, provides a systematic method to accurately localize native and prosthetic mitral valve regurgitant lesions. Also, paravalvular leaks may be more easily delineated and quantified using 3D echo. Due to accurate localization of the defects, this modality helps to improve the preoperative assessment and decisions about patients with significant mitral regurgitation.