1. Aortic Valve Peravalvular Leak

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

3. Rallidis et al (1999) u u Studied 84 consecutive patients with aortic valve replacements u u 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. u u 3 patients developed severe paraprosthetic regurgitation late related to endocarditis one patient had degenerative tissue valve failure. u u 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) u u Multi centre study: – –1,696 patients undergoing AVR – –39 (2.3%) with paraprosthetic leak u u Symptoms in patients with paraprosthetic leak – –71.4% Heart Failure – –17.8% Hemolysis – –10.8% none u u 28 people underwent surgery – –20/28 valve replaced – –8/28 Prosthetic leak closed by sutures – –surgical mortality 7%

5. Role of Echocardiographer Intraoperatively u u Preprocedure: – –Assess risk factors for Peravalvular leak u u annular calcification u u endocarditis/abscess u u 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. u u Define location and severity.

6. Illustration of Aortic Prosthesis Peravalvular Leak Case #1 u u Status post placement of prosthetic peravalvular leak noted immediately post bypass. u u Surgeon notified, location defined. u u 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 u u 58 yr old man presenting with bicuspid aortic valve with stenosis. u u Prebypass echo notes severe leaflet and annular calcification.

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

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

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

20. References: 1. 1. DeCicco, Beghi et al: Aortic Valve Periprosthetic Leakage: Anatomic Observations and Surgical Results. Ann Thorac Surg 2005;79:1480-5. 2. 2.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. 3. 3.O’Rourke et al: Outcome of Mild Periprosthetic Regurgitation Detected by Intraoperative Transesophageal Echocardiography. J Am Coll Card 2001;38:163-6.