1. Aortic Valve Peravalvular Leak

2. Risk factors for Aortic Valve Peravalvular Leak
Endocarditis
calcified annulus
bicuspid aortic valve
Note many present with significant annular calcification
Marfan Syndrome

3. Rallidis et al (1999)
Studied 84 consecutive patients with aortic valve replacements
Patients studied prospectively at early (11days), Mid (27months) and late (63 months) intervals.
40 patients developed leaks early, 90% of these were small and did not change over time. Patients did well.
3 patients developed severe paraprosthetic regurgitation late related to endocarditis one patient had degenerative tissue valve failure.
Concluded: Small leaks usually have a benign course. Development of new severe regurgitation should raise concern of endocarditis or prosthetic valve failure.

4. DeCicco et al (2005) Multi centre study:
1,696 patients undergoing AVR
39 (2.3%) with paraprosthetic leak
Symptoms in patients with paraprosthetic leak
71.4% Heart Failure
17.8% Hemolysis
10.8% none
28 people underwent surgery
20/28 valve replaced
8/28 Prosthetic leak closed by sutures
surgical mortality 7%

5. Role of Echocardiographer Intraoperatively
Preprocedure:
Assess risk factors for Peravalvular leak
annular calcification
endocarditis/abscess
Post aortic valve replacement
Diligently search for Peravalvular leak
Diligently search for fistula into RA/LA/RVOT Especially focus in areas of heavy calcium or abscess.
 Define location and severity.

6. Illustration of Aortic Prosthesis Peravalvular Leak Case #1
Status post placement of prosthetic peravalvular leak noted immediately post bypass.
Surgeon notified, location defined.
Surgeon able to place annular stitches off bypass. Leak no longer present. (not shown)

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8. Illustration of Aortic Prosthesis Peravalvular Leak Case #2
58 yr old man presenting with bicuspid aortic valve with stenosis.
Prebypass echo notes severe leaflet and annular calcification.

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11. Post Bypass Case #2
Note peravalvular leak, adjacent to left main coronary artery.
Peravalvular leak not addressed.

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14. Case #2 Patient returns 3 months later with symptoms.
On echo has peravavluar leak and prolapse prosthetic valve leaflet.

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19. Case #2
Patient under went successful aortic valve replacement without complications.

20.  References:
DeCicco, Beghi et al: Aortic Valve Periprosthetic Leakage: Anatomic Observations and Surgical Results. Ann Thorac Surg 2005;79:
Rallidis et al: Natural History of Early Aortic Paraprostheitc Regurgitation: A Five Year Follow-up. Am Heart J 1999 Aug;138(2Pt 1):351-7.
O’Rourke et al: Outcome of Mild Periprosthetic Regurgitation Detected by Intraoperative Transesophageal Echocardiography. J Am Coll Card 2001;38:163-6.