Mitral Valve Paravalvular Leak Closure

Mitral paravalvular leaks (PVL) occur when there is dehiscence between the prosthetic sewing ring and the native annulus, allowing blood to regurgitate around the valve rather than through it. The prosthesis itself may function normally, while a high velocity eccentric jet produces significant physiologic consequences. These leaks are often associated with annular calcification, endocarditis, friable tissue, or mechanical stress on the suture line over time. Even relatively small defects can cause severe hemolysis due to the intense shear forces generated as blood accelerates through the narrow paravalvular tract.

Patients may present with progressive heart failure, pulmonary hypertension, recurrent transfusion requirements, or unexplained hemolytic anemia. Elevated LDH, low haptoglobin, indirect hyperbilirubinemia, and schistocytes are common clues. Some patients have surprisingly normal-appearing prosthetic valve gradients despite profound symptoms because the pathology lies around the valve rather than through it. On echocardiography, these jets are frequently eccentric and difficult to characterize due to acoustic shadowing from the prosthesis. 3D TEE has become invaluable for defining the exact location, shape, and extent of the defect.

Percutaneous closure with Amplatzer vascular plugs has emerged as an important option for patients who are poor candidates for repeat surgery. Reoperative mitral valve surgery carries substantial risk, particularly in patients with multiple prior sternotomies, RV dysfunction, pulmonary hypertension, frailty, or active comorbid disease. Using transseptal or retrograde approaches, operators can cross the paravalvular defect and deploy occlusion devices directly within the leak channel while preserving prosthetic valve leaflet motion. Device sizing becomes critical because undersizing leaves residual regurgitation while oversizing risks obstruction of the prosthetic valve itself.

Here’s an example of a 3D TEE en face view of a TAVR valve in the mitral position, with paravalvular leak closure plugs at the 3 and 9 o’clock positions.