 Good morning. I'm pleased to present this talk on paravalval or leak assessment. Here are my disclosures. The objectives for this talk are to review the assessment of paravalval leaks with a focus on the aortic and mitral valves. I'm also going to present some cases demonstrating the procedural use of 3D echocardiography. For more details, I'm going to direct you to the published American as well as the European guidelines. They provide guidance for both surgical as well as percutaneous prosthetic valve assessments. Prostetica Paravalval leaks are actually quite common. The instance ranges between 5 to 17 percent in the literature. The instance is actually higher for valves placed in the mitral position with a published range of between 7 to 32 percent. For those in the aortic position, it's much lower between 2 to 10 percent. Typically, if you see an early paravalval leak, it's due to technical issues or from infection. If you see a late paravalval leak, it's usually from infection or angular calcification. Prostetic valves typically need to be assessed in a systematic manner. For the mitral valve, this requires interrogation of the valve in 30 degree increments from 0 to about 180 degrees. Images should be examined carefully to identify the origin of any leaks and to determine whether or not it's within the valve or external to the valve. Initially, at certain views, such as at the 120 degree views, we typically do sweeps in order to not to miss any paravalval leaks. If you look at this series of images, this is a mechanical mitral valve. All the leaks are accounted for and so there is no paravalval leak in this case. For the aortic valve, we typically start in the transgastric views and then we map similarly in 30 to 40 degree increments in order to see the aortic valve in the long axis as well as the short. For both the mitral and aortic valves, you want to be able to see the leaflets for mechanical valves in parallel so that you can ensure that they're opening and closing properly. The transgastric views are particularly valuable for aortic valve as there can be shadowing of the anterior annulus in the midisophageal views and so jets in that area may not be seen. Again, we try and do sweeps in order to make sure that the entire annulus is visualized and all jets are accounted for. Once we've gone in the transgastric views for aortic valves, we come up to the midisophageal and here you can see examples demonstrating why the posterior annulus is well seen on trans-isophageal echocardiograms versus on transtheracic. This area tends to be shadowed with mechanical aortic valves. In contrast to surface studies on trans-isophageal echocardiograms, the anterior annulus of the aortic valve is heavily shadowed and difficult to see. In the midisophageal views, typically we sweep from side to side or up and down from the LVOT up to the aorta in order to ensure that all jets are identified. For the mitral valve, 3D echocardiography has been particularly useful for identifying jets. So here we can see a color and non-color 3D on-fast view of the of a bioprostatic mitral valve and you can see the location of a large jet. There's some newer techniques that are being shown to be very helpful for assessing pair valve leaks, especially with the mitral valve. There is the development of this glass technique where the tissues are made more transparent. This allows you to find the origin of the jets and as well as the location of the ring and see if it is valvular or paravalvular. One technique that I find particularly useful is looking at the ventricular aspects of the valve with and without color. So here I have a bioprostatic mitral valve and as you can see on the left most image, there are multiple jets going in multiple directions from this valve and the question is whether or not there's a paravalvular leak. So in the second image from the left, I'm looking at the valve instead of from the atrial side and the ventricular side. This allows me to see the pizza of any large jets. Now smaller jets may not be seen or smaller pieces may not be seen if the volume rate is actually very low or if you've filtered up too much your 3D data set. So here we actually don't see any color coming from around the sewing ring and you can see the stretch very clearly as well as the sewing ring. The other thing is if we take this on a glass mode and we turn it on and then if you look at the third image from the left you can see that we've tilted it so we're looking at the ventricular side at the side aspect and you can see that the jet is coming from within the sewing ring and not outside of it especially since you can see the relationship with the jet to the struts. On the right most image we're now back in the left atrial view and we're on a glass view and we've tilted and you can see how it can be very difficult to know however with this view you can actually slow down the jet and you can see it as it comes and the origin where it comes on from the valve. Now we know from a lot of studies that the location might show a pair of valve leaks tend to be posteriorly and this is for several reasons. First because it's just a location in the surgical field. Second because of the course of the circumflex in that area surgeons tend to take a shallower bite to try and protect the circumflex artery. Another reason is because there's an increased prevalence of calcium fibrosis in this area and that makes it difficult to sew the valve annulus into that region. Finally the anterior portion of the annulus has the mitral fibrosis which is very rigid and can tether the valve putting an increase in pressure on this posterior part of the valve. Aortic pair of valve leaks on the other hand tend to be more commonly located along the quote sort of non-cornery or right coronary cusps as you can see on these examples here. Now once you've identified your leak how do you know how to describe it and especially when you've got a case where there are multiple leaks so we know that up to 27 percent of patients may have more than one leak present. A couple methods have been used for the mitral valve. First some have taken the carpentia mitral valve classification and tried to extrapolate it to a prosthetic valve. However the problem with prosthetic valves is there's no natural landmarks as there are on a native valve to allow you to identify the scalps and so there could be huge variability between individuals in terms of reporting where the location of the leak is located. Others have tried breaking the valve into quadrants and you'll still see some readers reporting valve leakages in this manner and breaking down into an anterior aseptal posture as well as the lateral quadrant. However these quadrants are quite big and so if you look at the posterior quadrant there's a jet there but it's closer to the location of the septal wall than it is the posterior wall and so that lack of precision can make it challenging to direct your interventionalists when you're communicating with them. So the most common way that paravital leak location is communicated is using this clock system. Now this clock system was first suggested in this initial paper. However if you look at this initial paper you'll notice that the 11 o'clock position is actually where the aortic valve is located and then this results in a four chamber view where you have the 12 and 6 o'clock positions noted, a two chamber view with the three and nine o'clock positions noted, and a three chamber view where the five and 11 o'clock positions are noted. However as this clock system has been integrated into guidelines the 12 o'clock position has actually rotated and now it is located mainly at the location of the aortic valve. The clock system is also used for reporting aortic paravital leak positions except in this case the RVOT is where the 12 o'clock is located, the PA is where the three o'clock is located, the left atrium is where the six o'clock would be located, and the right atrium where the nine o'clock position would be located. Once you've located your paravital leak you also have to provide an idea of the size and the shape. We know from many of these 3D studies that often the shape of the paravital leaks may be very eccentric and so often they're crescentic in nature and the path through from the left atrium to the ventricle can be very surpigenous. Sometimes the paravital leaks can actually come with quite complicated anatomy. Here we see this is a repair deortic root in a patient had infective endocarditis and you see there's dehiscence of the reconstructed root posteriorly, there's a leak anteriorly as well as from the to his segments. In this case you just have to first describe the dehiscence as followed by the locations of the leak and then an assessment of the size as much as possible. Now quantification of the severity of the regurgitation in paravital leaks is very similar to that used for native leaks except the only addition is the assessment of the circumferential extent of the leak and the numbers you have to remember for the mitral valve is 10% and 30%. If the circumferential extent of the leak is less than 10% then it's a mild leak. If it's greater than 30% then it's severe. However one of the things about the circumferential cutoff is that it doesn't take into account the depth of the leak. So you can have something that's less than 10% but if it measures 10 millimeters in size then that's still probably going to be a severe leak rather than mild. Similarly the aortic assessment of aortic paravital leak severity is reliant on assessment criteria from native aortic valve for regurgitation except for the addition of the circumferential assessment. Once again the cutoff values are similar 10% and 30% with less than 10% being mild and more than 30% being severe. With the advent of tower valves we generally find it very difficult to add up all these circumferential lesions as there may be multiple discreased jets and that makes it more challenging in those valves. We have a lot of percutaneous options now for paravital leaks and so many patients instead of going straight for surgery or undergoing percutaneous procedures here is an example of a mechanical valve with a percutaneous device in place. On the right you can see there's a series of different percutaneous devices demonstrated. 3D echocardiography in addition to assessing severity and location of the valves, paravalve leaks is useful for guiding procedures. Here we see on the left guidance of the transeptal puncture and then on the top right you can see the catheter with the wire going through the paravalve leak which is located anteriorly in this mitral valve and then you have an off-axis view showing the path of the wire from the septum through the valve into the ventricle. Most places are slowly integrating this new fusion technology which allows you to fuse the transephageal echo images to the fluoro. Here's an earlier version of that where a mark is placed on the transephageal image of the location of the paravalve leak and this mark then shows up on the fluoroscopic picture that the interventionalist sees. Echocardiography is very important also for procedural complications during these paravalveler procedures. Here is a mechanical mitral valve and you can see there's a catheter coming across the septum and going into the device and then you can see there's one device already placed and then there's the catheter and then on the image on the left you can see that the two discs are moving nicely and they're opening very wide and parallel when they're open and then on the second image to the right you can see that one disc is now fixed and not moving at all and the other disc has restricted motion. Other complications that can be seen on echocardiography include device embolization as well as movement once the device has been released. Overall, while this talk is mostly focused on the use of transephageal echocardiography, transthoracic as well as other imaging modalities such as cardiac CT and cardiac MRI play an important role in the assessment of paravalveler leaks. Now I'm going to demonstrate some cases. This is a 77-year-old female who has a history of rheumatic mitral valve disease. She had a tissue mitral valve replacement in 2009. She presents in April of 2019 with severe prosthetic valvular and paravalval regurgitation. Now if you look at the top two images you see that there is a bioprostatic mitral valve. The top left has no color. The top right has color and can appreciate the valvular regurgitation jet that's directed interlaterally. Now when we take this image and we rotate it and we're off axis now we can actually appreciate both the valvular as well as the paravalval leak. So this patient ended up having a valve and valve procedure to treat the valvular leak and this is after that valve and valve procedure and so you can see that there's a nice new bioprostatic valve in the mitral valve position and now we can actually truly appreciate the size of the paravalval leak. So the top two images with and without color show the location of that paravalval leak and then on the left most image you can see that we've rotated it to a non-onfast plane so we can actually see the hole and then there are two images on the bottom that are taking the 3D datasets and one is with color and one is without color where we've actually moved the planes so that we are cutting through the leak and you can see that's a very christened shape and this allows us to get a measurement and eventually plan to place a device there. Now let's look at this other case this is an 80 year old general with a bioprostatic mitral valve replaced in 1983 then he had a rejuve of valve surgery in 1997 with a mechanical valve and then he required a third rejuve operation in 2013 and was given a tissue valve at that point. He was found to have a pair of valve leak due to multiple surgeries he was not offered another surgical option but underwent a percutaneous procedure in 2017 and on the pictures on the right at the top and bottom you can see at the 11 o'clock position there is one of the devices that was placed however he still was left with some pair of valve leaks you can see there's one right next to the original device at 11 o'clock and there's a second smaller leak at about five o'clock or located posteriorly so because he returned with anemia caused from the hemolysis that required transfusion he underwent another procedure so here's a series of images showing his procedure so on the top left images you can see there's a color and non-color image showing the catheter and the wire as we are crossing next to the original device with a wire you can see that the wire has gone through on the middle image and the device is still in place then on the top right most images you see a color and non-color showing that two devices are now there at the 11 o'clock position there is still residual jet coming from between the two devices but it's not as significant as it was before if you look at the bottom row of fluoroscopic images you can see the matching images that were taken at the same time as the TE and with the left most fluoroscopic image showing the wire crossing the pair of Avalolique and then the middle image showing the deployment of the second device next to the original device and then the final right most image showing the two devices in place after they've been released so in summary pair of Avalolique assessment includes identification of a note number location size shape and regurgitation severity for the mitral as well as the aortic valves you have to look at both the mid esophageal for the mitral valve and the transgaftric for the esophageal you need to use a standard systematic way to increase your angle as you assess as well as looming sweeps to ensure that you're not missing any any leaks 3d echocardiography is very helpful for location as well as sizing of these leaks it's also useful for percutaneous device placement and assessment of complications and residual regurgitation i'd like to acknowledge the structural program in obtaining some of these images thank you for listening