Pre- and Intraprocedural Imaging Considerations in Paravalvular Leak Closure

Paravalvular regurgitationParavalvular regurgitation or leak (PVL) is not an uncommon complication of prosthetic valve disease and can be associated with severe heart failure, hemolytic anemia, or both. The management of these patients often having multiple comorbidities is challenging and the choice between surgical intervention, transcatheter closureTranscatheter closure and medical treatment should be decided by the Heart Team on a case-by-case basis. Transcatheter PVL closure has emerged as an attractive and efficient treatment option for these patients and the success of the procedure relies on a careful pre-procedural evaluation, for selecting the patients suitable for a transcatheter interventionTranscatheter intervention, and expert imaging guidance during the procedure. Pre-procedural evaluation should determine the location and the number of the jets and the severity of the PVL. Echocardiography holds a central role in the pre-procedural evaluation of patients with PVLs, but other imaging modalities, such as cardiac magnetic resonance imaging (CMR) and cardiac computed tomography (CT) can offer useful adjunctive information for grading the severity of the regurgitation and for selecting the type and the size of the prosthesis. The intervention is performed under fluoroscopic and transesophageal/intra-cardiac echocardiographic guidance. The use of fusion imaging can facilitate the delivery of the device. Echocardiography has an important role on the procedural guidance, being especially useful for selecting the size of the device(s), confirming the correct location of the device(s) and its lack of interference with the prosthetic valve function or adjacent structures (such as the coronary arteries for aortic PVLs) and for evaluating the presence of complications. A good communication between the echocardiographer and the interventional cardiologist, at every step of the procedure, is essential for the success of the intervention.