Periprosthetic Valve Leaks

KEY FEATURES

ESSENTIALS OF DIAGNOSIS

• New murmur in a patient with a prosthetic valve or a regurgitant murmur ascribed to the prosthetic valve

• Echocardiographic evidence of perivalvular leak

• Clinical deterioration, embolism, or hemolysis

GENERAL CONSIDERATIONS

• A periprosthetic valve leak is regurgitation between the native valve ring and the prosthesis sewing ring or stent in stent-mounted valves

• Small periprosthetic leaks often occur immediately after surgery or transcatheter procedures and are detected by transesophageal echocardiography in the hybrid operating room

  • – Resolve in days to weeks as the prosthetic ring/stent becomes endothelialized

• Persistent periprosthetic leaks can enlarge rapidly, requiring reoperation, but they usually remain stable for years

• The incidence of persistent perivalvular leak is high with calcified mitral annulus and preoperative endocarditis

• A new periprosthetic leak suggests infective endocarditis

• Rarely, a periprosthetic leak causes enough sheer stress on red cells to produce clinically significant hemolysis

CLINICAL PRESENTATION

SYMPTOMS AND SIGNS

• Usually asymptomatic

• Fatigue and dyspnea on exertion if anemic due to hemolysis

• Fever, sweats, malaise if endocarditis is present

• Heart failure symptoms if leak is hemodynamically significant

PHYSICAL EXAM FINDINGS

• New systolic murmur (mitral and tricuspid)

• New diastolic murmur (aortic and pulmonic)

• Pallor

• Enlarged ventricular impulses

• Thrill

• Peripheral signs of endocarditis

• Signs of heart failure

DIFFERENTIAL DIAGNOSIS

• Prosthetic valve malfunction: thrombus, vegetation, or pannus

• Infective endocarditis without periprosthetic leak

• Hemolysis due to prosthesis malfunction or other causes

• Embolism from thrombus formation

• Clinical deterioration for other reasons (eg, prosthesis too small)

DIAGNOSTIC EVALUATION

LABORATORY TESTS

• Low hematocrit, elevated lactic dehydrogenase, elevated bilirubin, hemoglobinuria, and a positive blood smear for fragmented cells if hemolysis is present

• Positive blood cultures if endocarditis is present

ELECTROCARDIOGRAPHY

• ECG findings:

  • – Tachycardia

  • – Chamber enlargement

IMAGING STUDIES

• Chest x-ray finding: cardiac chamber enlargement

• Fluoroscopy can detect:

  • – Abnormal mechanical prosthetic valve function

  • – The rocking motion of partial valve dehiscence

• Echocardiography findings:

  • – Chamber enlargement is seen with hemodynamically significant lesions

  • – Prosthetic valve rocking may be seen with partial dehiscence

  • – Evidence of vegetations may be present

  • – Prosthetic valve abnormalities may be detected, suggesting a valvular rather than perivalvular etiology

• Doppler echocardiography:

  • – Color-flow Doppler usually is critical in identifying the site and cause of regurgitation and defining its severity

DIAGNOSTIC PROCEDURES

• Transesophageal echocardiography may be necessary to define the exact site and cause of regurgitation and diagnose prosthetic valve dysfunction or endocarditis

• Cardiac catheterization is rarely needed to make the diagnosis but may be necessary to define coronary anatomy or confirm the hemodynamic consequences of valve malfunction before ...