Paravalvular aortic leak after transcatheter aortic valve replacement: current knowledge.

397 T ranscatheter aortic valve replacement (TAVR) is now well-established as the standard of care for patients with severe symptomatic aortic stenosis who are deemed inoperable , 1 and is seen as an alternative treatment option to surgical aortic valve replacement (SAVR) in a subset of patients with high postoperative mortality. 2 The native valve is typically not removed but instead crushed by the superimposed bioprosthe-sis, which can result in an incomplete seal of the bioprosthetic valve and aortic annulus, with subsequent occurrence of para-valvular leak (PVL). Two types of Transcatheter Heart Valves (THV) that have been widely used, the balloon-expandable Edwards valve (Cribier-Edwards, Edwards SAPIEN and Edwards SAPIEN XT) by Edwards Lifesciences, and the self-expandable CoreValve by Medtronic, have been described in detail elsewhere. 3,4 Despite the evolving technology of trans-catheter valves, PVL post-TAVR is common, with a wide range of reported incidences (Table 1). Most importantly, PVL has been associated with increased short-and long-term mortality post-TAVR, and is seen as a barrier to more widespread use of this promising technique. 5–13 This article describes the incidence, causes, and predictors of PVL, as well as its impact on clinical outcomes. Methods of prevention, diagnosis, and treatment of PVL are also reviewed. Aortic regurgitation is characterized as either central or para-valvular. Pathological central regurgitation occurs in diseased native valves or damaged prosthetic valves, whereas minor central regurgitation is often a physiological feature of some bioprosthetic valves by virtue of their design. On the other hand, PVL is a complication only of aortic valve prostheses and occurs more commonly post-TAVR (Figure 1) than after SAVR. Various multicenter registries and trials have reported data on incidence of PVL post-TAVR at different time points (Table 1). The overall incidence of PVL post-TAVR ranges between 50% and 85%, which is significantly higher than what has been observed in SAVR, reported between 1% and 47.6%, with only 4.2% consisting of more than mild PVL. The largest meta-analysis of TAVR outcomes estimates the incidence of residual moderate or severe aortic regurgitation after TAVR to be 7.4%. 27 The UK TAVR registry suggests moderate-severe PVL occurred more commonly with CoreValve implants (17.3%, versus 9.6% with the Edwards implants). 13 This finding has not been replicated in other studies. One study by Ewe et al 21 did not find a statistically significant difference in incidence of PVL between transfemoral and transapical TAVR at 30 days and 6 months. …