**6. Transcatheter paravalvular leak closure**

After a full assessment, defining *the objective* of the procedure is primordial; in the case of heart failure presentation, every PVL reduction is beneficial. When the TPVL is motivated by hemolytic anemia it is important to achieve a total closure of the PVL.

TPVL planification includes the choice of an adequate approach and devices. The procedure is usually performed in a catheter laboratory under general anesthesia and joint TEE and fluoroscopy guidance. Antibiotic prophylaxis is applied by administration of a cephalosporine or vancomycin in case of penicillin anaphylaxis. Nonfractioned heparin is administrated to obtain an active cephalin time between 250 and 300 and prevent catheter thrombosis. These are generally long procedures; the use of fluoroscopy is optimized to 7.5 images/second and the use of a higher image frame rate (15 images/second) is restricted to necessary (device delivery).

*Approaches:* For the mitral valve, the anterograde transeptal approach is the most used, however, an anterograde transaortic approach is more suitable for septal and posterior PVLs. The combination of both approaches forming an arteriovenous loop and transapical access are alternatives particularly for large or multiple PVLs necessitating the use of multiple devices [21]. The retrograde approach is not feasible in the case of mechanical aortic valve (**Figure 2**).

#### **Table 3.**

*Characteristics of dedicated paravalvular leak devices.*

#### **Figure 3.**

*Illustration of steps of a complex mitral lateral and posterior paravalvular leak transcutaneous closure in a 52-years-old female with an aortic valve prosthesis and a Starr mitral valve prosthesis. A: Paravalvular leak in color Doppler transesophageal echocardiography. B: Assessment of the defect by three-dimensional transesophageal echocardiography. C: The septal tenting. prior to the septal crossing by the wire. D: crossing of the paravalvular leak by the delivery catheter. E: assessment of the occluder device deploying by fluoroscopy and echocardiography and verification of the prosthetic valve flow. F: final result assessment by fluoroscopy and three-dimensional echography after delivery of one lateral and two posterior devices (arrows).*

*Paravalvular Leaks: From Diagnosis to Management DOI: http://dx.doi.org/10.5772/intechopen.106177*

For the aortic valve is concerned, the retrograde approach is the most used, and transapical approach, which is useful for multiple and complex PVLs [26].

*Devices:* Rare dedicated devices were designed by manufacturers; Amplatzer vascular plug III (Abbott Vascular) and the paravalvular leak device (Occlutech), they are theoretically more suitable than non-dedicated devices. Their characteristics are summarized in **Table 3**.

Other non-dedicated devices were used for TPVL amplatzer vascular plug II and IV (Abbott Vascular), amplatzer duct occluder devices (Saint Jude Medical), atrial septal defect, and ventricular septal defect devices.

All devices are used off-label and do not have FDA approval [27].

The use of multiple devices can be necessary for large or multiple PVLs. This can be achieved one or more times [5].

*Delivery sheaths*: There is no dedicated delivery sheaths for PVL dedicated devices. Delivery sheaths for atrial septum, ventricular septum, or arterial duct devices adapted for PVL may have an insufficient length for aortic PVLs or nonoptimal diameters. Steerable sheaths facilitate the procedure and are imperative in mitral posteroseptal PVLs.

**Figure 3** illustrates the main steps of a TEE-guided mitral TPVL.
