17323 Paravalvular Leak Closure

Overview

A paravalvular leak (say: pa-ra-val-VYOO-ler) is a small gap between a replacement heart valve and the heart tissue around it. The valve is the one-way door in your heart that keeps blood flowing the right way. When there is a gap beside the valve, a little blood slips backwards through it. 'Closure' means sealing that gap. Doctors often do this with a thin, flexible tube called a catheter that goes through a blood vessel, so the chest does not need to be opened.

It is not common. It affects only a small number of people who have had a heart valve replaced. How often it happens depends on which valve was replaced and on the person's heart tissue.

It affects people who have a replacement heart valve, whether mechanical or made from animal tissue. It is seen most often after mitral valve replacement (the valve on the left side of the heart). It can affect older adults more often, because their valve rings are more likely to be chalky and stiff, and it can also affect children born with heart problems who have had valve surgery.

Symptoms

Common symptoms

• Shortness of breath when you walk, climb stairs or carry shopping
• Feeling unusually tired or low on energy
• Swelling in the ankles, legs or tummy
• A fluttering, pounding or racing heartbeat (palpitations)
• Feeling dizzy or light-headed
• Pale skin, dark urine or feeling weak — signs that red blood cells are being damaged as they pass through the leak
• No symptoms at all — sometimes a leak is only found during a routine check

Symptoms in children

• Tiring quickly during play or sport
• Sweating or breathing hard during feeds
• Poor feeding and slow weight gain
• Paler skin than usual or less energy than other children
• Being smaller or growing more slowly than expected

Symptoms in older adults

• Breathlessness doing everyday tasks that used to feel easy
• More tiredness and needing to rest during the day
• Swollen ankles or a bloated tummy
• Putting on weight quickly because of extra fluid
• Feeling light-headed when standing up

Causes

Main causes

• The stitches that hold the replacement valve in place pull away from the heart tissue, leaving a gap
• The ring of heart tissue around the valve is rough, chalky or uneven, so the valve does not sit snugly
• The tissue around the valve is weak or thin, sometimes because of age or a connective tissue condition
• An infection on the valve (endocarditis) damages the tissue around it
• A small tear in the tissue can happen during valve surgery

Risk factors

• Having had heart valve replacement surgery, especially of the mitral valve
• Heavy calcium (chalky) deposits in the valve ring
• Having a second or repeat valve operation
• A previous infection of the heart valve
• Older age and weaker heart tissue
• Connective tissue conditions that make tissue stretchier or weaker

When to see a doctor

See a doctor urgently if:

• You are more breathless than usual, or breathless at rest
• You have new swelling or fast weight gain from fluid
• You have a fever that does not have an obvious cause
• You feel faint, dizzy or have a racing heartbeat that will not settle
• You have dark urine or feel very pale and weak

Book a routine appointment if:

• You feel more tired than usual over weeks
• You are less able to manage your normal activities
• You have a follow-up appointment and want to talk about symptoms
• You have questions about your replacement valve or your medicines

Diagnosis

Your doctor starts by asking about your symptoms and listening to your heart with a stethoscope. A leak often makes a whooshing sound called a murmur. The key test is an ultrasound of the heart (echocardiogram), which shows the valve, the gap and how much blood is leaking back. Your team will also want to know how well your heart is coping and whether the leak is causing anaemia (low red blood cells) from cells being damaged as they pass through the gap.

Tests that may be done

• Echocardiogram — a painless ultrasound scan of the heart
• Transoesophageal echocardiogram — a scan using a thin probe passed gently down the throat to see the valve more clearly
• Colour Doppler — part of the scan that shows the direction and amount of leaking blood
• Blood tests — to check for anaemia, red blood cell damage and infection
• Electrocardiogram (ECG) — a tracing of your heart's rhythm
• Chest X-ray — to see the heart's size and check the lungs
• Cardiac CT or MRI scan — detailed pictures to plan a closure procedure
• Cardiac catheterisation — a thin tube used to measure pressures inside the heart

What to expect at your appointment

Most tests are quick and painless. For a standard echocardiogram you lie on a couch while gel and a small probe are moved over your chest. For the probe-down-the-throat scan, your throat is numbed and you may be given light sedation, so arrange for someone to take you home. Your team will explain what each test is for and when to expect results. It is fine to bring a list of questions.

Treatment

The aim is to stop blood leaking backwards so your heart does not have to work so hard. Treatment depends on how big the leak is, how much it affects you and how well your heart is coping. Options range from careful watching with regular checks, through a catheter procedure to seal the gap, to open-heart surgery in some cases.

Self-care at home

• Weigh yourself at the same time each day and write it down — tell your team about fast weight gain
• Keep a simple note of your breathlessness, swelling and energy levels
• Take all medicines exactly as prescribed and ask your pharmacist if you are unsure
• Keep your teeth and gums healthy and see your dentist regularly — this helps protect your valve from infection
• Stay gently active, building up slowly, unless your team tells you otherwise
• Follow any advice about salt and fluid limits
• Carry information about your replacement valve and any procedure you have had
• Avoid smoking and get help to stop if you smoke

Medical treatments

Your heart team may prescribe medicines to help your heart pump more strongly, to remove extra fluid from the body, or to treat anaemia or an infection. They may also review blood-thinning medicines if you have them. You will have regular check-ups and scans to see whether the leak is stable or changing. Your team will discuss the pros and cons of each option with you, and the final choice is yours.

When is surgery considered?

A catheter procedure is often the first choice when the gap is suitable. A thin tube is guided through a blood vessel, usually in the groin, up to the heart, and a small plug-like device is placed in the gap to seal it. You may be asleep or lightly sedated. If the gap is very large, in an awkward position, or if the valve itself is failing, open-heart surgery to repair or replace the valve may be recommended. Your team will explain which option fits your heart and your general health.

Living with this condition

Life with a replacement valve and a leak is usually manageable with some planning. Pace your activities, rest when you need to, and keep your follow-up appointments. Many people find that after closure their breathing and energy improve over weeks to months. It helps to know your own warning signs — such as a jump on the scales or a return of ankle swelling — and to act early.

Lifestyle tips

• Build activity up gradually and stop if you feel chest pain, dizziness or severe breathlessness
• Keep to a healthy weight and eat a balanced diet
• Limit salt if your team advises it, as salt makes the body hold fluid
• Avoid heavy lifting and straining until your team says it is safe after a procedure
• Keep up with dental check-ups and tell your dentist about your valve
• Ask about travel, driving and returning to work — the advice depends on your procedure
• Keep a card or note with your valve and procedure details in case you need medical care elsewhere

Diet and exercise

A heart-friendly diet with plenty of vegetables, fruit, whole grains, beans and fish, and less salt and processed food, supports your heart. Exercise helps your heart and muscles work better, but with a leak you should build up slowly. Walking, swimming and gentle cycling are good choices. Ask your team or a physiotherapist about a cardiac rehabilitation programme, which gives you a safe plan and people to exercise with.

Mental health and emotional wellbeing

It is very normal to feel anxious before a procedure, or to worry about your heart when you feel a flutter or a bit breathless. Some people feel low or frightened after heart treatment. These feelings usually ease, but they deserve attention. Talk to your doctor, nurse or a counsellor — help is available and you are not wasting anyone's time. If you ever feel hopeless or have thoughts of harming yourself, contact your local emergency number or a crisis helpline straight away.

Prevention

You cannot always prevent a leak around a replacement valve, because it depends on how the valve sits in your heart tissue. But you can lower some risks: keep your teeth and gums healthy, treat infections promptly, take your medicines as prescribed, and go to your follow-up scans so any change is picked up early.

Vaccines

Keep up with the vaccinations your team recommends, such as flu and pneumonia vaccines. Ask your GP or pharmacist which ones are right for you.

Screening programmes

If you have a replacement valve, you will usually have regular echocardiograms to check how it is working. These follow-up checks are the best way to spot a leak early, even if you feel well.

Complications

If left untreated

• Heart failure — the heart becomes stretched and struggles to pump
• Anaemia from red blood cells being damaged as they pass through the leak
• Infection of the valve (endocarditis), which is serious and needs urgent treatment
• Irregular heart rhythms
• Gradual loss of energy and ability to do everyday activities
• In some cases, strain on the heart that is harder to reverse if left a long time

Long-term outlook

The outlook is generally good. Many people who have a leak closed notice less breathlessness, more energy and less swelling, and their heart works better. Recovery takes weeks rather than days, and you will need follow-up checks. Some people need a repeat procedure later on. Your team will talk honestly with you about what to expect for your own heart, and there is support at every stage.

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