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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 repeat surgery or transcatheter procedure

TREATMENT

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