Paravalvular leak

[Pete81]

Something that has been on my mind a lot is the fact that since about a year or so I know that there’s a gradient over my St Jude 25mm that went in about four years ago. I had my surgery done in the UK but have since relocated to the Netherlands. This is where the consultant found that a) there’s a paravalvular leak and b) it is causing a gradient over the valve. I can still do all sports that I want (except maybe kickboxing) so no limits on straining the heart there which is a comforting thought but still. I have read this type of leak is common but I was just wondering if anyone else here has had this type of leak and what your experiences are with this phenomenon. Even though I have been a Mech-valver for almost four years now, I still get stressed out from time to time thinking about the possible consequences of things just not working they way they should such as this leak.

 

[pellicle]

as I understand it paravalvular leak progresses and there is no sudden failure.
A Quick Guide to Paravalvular Leak Closure

So, unlike aneurysm which does just rupture without warning, I understand that its a case of monitor and see changes.

I recall someone else discussed this here, got worked up about it and then it was patched and they don't post anymore.

So

best wishes

 

[Pete81]

as I understand it paravalvular leak progresses and there is no sudden failure.
A Quick Guide to Paravalvular Leak Closure

So, unlike aneurysm which does just rupture without warning, I understand that its a case of monitor and see changes.

I recall someone else discussed this here, got worked up about it and then it was patched and they don't post anymore.

So
View attachment 887384

best wishes

Thanks Pellicle I have annual check-ups now but had a few extra ones after the first observations. Had lots of things ruled out such as endocarditis by PET scanning etc. Things seem stable now of which I hope it stays like that, and won’t, as you mentioned, progress but maybe it is inevitable that one thing will lead to another. Outcomes and perspective always seem so bleak in these scientific publications, maybe that the result of the authors highlighting the urgency of the work presented. Maybe it is just me in need of some good news every now and then...

 

[pellicle]

Outcomes and perspective always seem so bleak in these scientific publications

outcomes are steered by your perspective.

I haven't seen anything overtly positive since 2012 ... so instead I choose to slant what I see as positve.

life is what you make of it ... I'm not the man I was at 20, instead I'm the man I am now

 

[charlottekaye]

Something that has been on my mind a lot is the fact that since about a year or so I know that there’s a gradient over my St Jude 25mm that went in about four years ago. I had my surgery done in the UK but have since relocated to the Netherlands. This is where the consultant found that a) there’s a paravalvular leak and b) it is causing a gradient over the valve. I can still do all sports that I want (except maybe kickboxing) so no limits on straining the heart there which is a comforting thought but still. I have read this type of leak is common but I was just wondering if anyone else here has had this type of leak and what your experiences are with this phenomenon. Even though I have been a Mech-valver for almost four years now, I still get stressed out from time to time thinking about the possible consequences of things just not working they way they should such as this leak.

I have a paravalvular leak which has been monitored for a long while. (Mechanical valve is just over 23 years old.) I have noticed some changes in the way I feel over the past 5 years, which is a little upsetting to me because this is my 2nd valve. But, there are other factors that could explain the gradual decline in the way I feel. I am a little overdue for a check-up because of COVID-19, but I will have it soon, and I will post after the appointment. Meanwhile, don't worry. But - don't be kickboxing, either!!

 

[catwoman]

I have a paravalvular leak. It was detected about 2 years after my MVR (2003). After that cardiologist retired, I switched practices around. 2008 and after an echo there, the new cardio ordered a TEE. He said that it was stable and could remain stable for years. I have not had a TEE repeat since then but have annual echoes.

 

[nobog]

This is where the consultant found that a) there’s a paravalvular leak and b) it is causing a gradient

I'd get a new consultant, a PV leak, if anything, would lower the gradient (pressure drop) across the valve, as there is an additional path for flow. The trend, seemingly forever, has been to stuff the largest size valve into the smallest size hole - or "over size it" to get a lower pressure drop (gradient). How do they do this? They put the thinnest cuff possible that still resembles a cuff on the valve, so a valve that starts its life as a 21mm is now a 23mm. But the cuff is the "gasket" and with next to nothing to start with I'm not surprise to see these PV leaks show up.

If I was to have a valve, it would be the standard size with a nice big fluffy cuff (not a "supra" or "high performance") - that way the surgeon has a reasonable shot at plugging up every sq mm between the valve - and me.

 

[Astro]

It is good that you are keeping an eye on it.

Regurgitation generally has little impact on exercise tolerance unless it is very severe (which wouldn't be the case around your valve). Getting the right anticoagulation levels is important to decrease the risk of a stroke. Expert opinion about what INR to aim for would be helpful.

The medical literature can be confronting. However, most people who have a valve replacement and paravalvular leak are not as fit as you. Few would have the fitness to do sport like you. For this reason, the studies do not actually relate your risk, which would be lower.

 

[Agian]

This is where the consultant found that a) there’s a paravalvular leak and b) it is causing a gradient

I'd get a new consultant, a PV leak, if anything, would lower the gradient (pressure drop) across the valve, as there is an additional path for flow. The trend, seemingly forever, has been to stuff the largest size valve into the smallest size hole - or "over size it" to get a lower pressure drop (gradient). How do they do this? They put the thinnest cuff possible that still resembles a cuff on the valve, so a valve that starts its life as a 21mm is now a 23mm. But the cuff is the "gasket" and with next to nothing to start with I'm not surprise to see these PV leaks show up.

If I was to have a valve, it would be the standard size with a nice big fluffy cuff (not a "supra" or "high performance") - that way the surgeon has a reasonable shot at plugging up every sq mm between the valve - and me.

Hmm, that makes sense. But wouldn't the cuff size depend on the make of valve?

 

[nobog]

Hmm, that makes sense. But wouldn't the cuff size depend on the make of valve?

I'm not at liberty to mention which brand but at one time there were 7 different cuffs just for the aortic version. Different fillers, materials, diameters, shapes, rotation mechanisms, are all among the possibilities.

Valve sizes are sold by tissue annulus diameter (in general - somewhere in the middle or inner edge of the cuff) and not by valve inside diameter or frame diameter.

 

[Pete81]

Thanks for sharing, I do hope you will be able to get your check-up soon and you’re alright. As far as sports, I am taking it easy, I run and that’s a great way to let things go.

 

[Pete81]

Thanks for Sharing your thoughts on this. I have to say I feel extremely lucky with the expertise center I am a patient and from where I am being monitored. I have a lot of confidence in my cardiologist but what you are saying does also make sense to me. It does make me wonder though if a gradient could be present over just the leak? Surely that would also be the cause of any haemolytic anemia right? I checked my latest results, it does mention a 25mm Hg gradient, perhaps I should ask for a detailed explanation next time I am in again.

 

[Astro]

Thanks for Sharing your thoughts on this. I have to say I feel extremely lucky with the expertise center I am a patient and from where I am being monitored. I have a lot of confidence in my cardiologist but what you are saying does also make sense to me. It does make me wonder though if a gradient could be present over just the leak? Surely that would also be the cause of any haemolytic anemia right? I checked my latest results, it does mention a 25mm Hg gradient, perhaps I should ask for a detailed explanation next time I am in again.

Hi Pete81,

A gradient usually refers to stenosis rather than regurgitation. The significance of 25 mmHg will depend upon whether it is mean gradient or peak gradient. If it is mean gradient:
< 20 mmHg mild stenosis
20-40 mmHg moderate stenosis (mean 25 mmHg corresponds to low moderate stenosis)
>40 mmHg severe stenosis
If the 25mmHg is peak gradient, the stenosis is only mild.
(I haven't seen regurgitation discussed as a gradient - it is measured as volume)
I suspect that you have both some regurgitation and stenosis (yes you can have both).

These will be good questions for your cardiologist.