**3. Clinical and subclinical manifestations**

The three main clinical manifestations of PVLs consist of congestive heart failure (HF), anemia, and IE [9].

*Congestive HF* occurs in the case of large or multiple PVLs with a severe valve regurgitation.

While *hemolytic anemia syndrome* occurs in small PVLs. They are more frequent in mitral valves with preserved LVEF [10], which results in a high velocity and turbulent systolic regurgitant jet. Hemolysis and anemia may be permanent or intermittent. Hence, a partial improvement during follow-up should not exclude the diagnosis nor lead to investigation cessation.

*Infective endocarditis* syndrome may be secondary to a previous mechanical known or unknown disinsertion or the cause of the valve disinsertion. It is important to detect IE for specific treatment. TPVL is contraindicated in this case.

*Clinical tolerance* is not directly correlated to the size of the PVL [9], it is influenced by several factors, including the compliance of cardiac chambers compliance, ventricular functions, the existence and degree of anemia, and the rapidity of installation. Symptomatic patients are at the tip of the iceberg.

*Subclinical PVLs* are more frequent, they can remain stable and or lead to progressive heart function deterioration, or they can be unmasked by an intercurrent event like IE.

Subclinical PVLs were reported to affect the patient's prognosis in SAVR and in TAVR [11, 12], they require a close follow-up and IE prevention. While symptomatic PVLs have a severe prognosis and an intervention, when feasible, is needed to improve their outcome [13].


#### **Table 1.**

*Factors contributing to paravalvular leak occurrence after a surgical valve replacement.*

We should have a high index of PVL's suspicion when a patient presents with one of these figures even if first-line investigations, namely, transthoracic echocardiography (TTE) is negative. This is an essential step toward the diagnosis.
