Journal of Echocardiography
https://doi.org/10.1007/s12574-021-00553-6

CASE IMAGE IN CARDIOVASCULAR ULTRASOUND

Paravalvular leak vanishing at end‑diastole during transcatheter aorticvalve replacement
Yoji Tamaki1 · Shingo Tsujinaga1 · Hiroyuki Iwano1· Kiwamu Kamiya1 · Toshiyuki Nagai1 · Toshihisa Anzai1

Received: 6 August 2021 / Revised: 22 September 2021 / Accepted: 28 September 2021
© Japanese Society of Echocardiography 2021

A 90-year-old woman underwent transcatheter aortic valve
replacement (TAVR). After the implantation of a selfexpandable valve, paravalvular leak (PVL) was found at
posteromedial side (Fig. 1a, b). The regurgitation jet on
the color Doppler image was not enough to confirm thepresence of severe regurgitation because of the vanishingat end-diastole (Fig. 1c, Supplementary video 1), although
circumferential extent of the PVL occupied > 30% and aholodiastolic flow reversal was observed in the descending
aorta. Soon after, the patient’s blood pressure dropped from
123/70 mmHg to 93/30 mmHg. There were neither electrocardiogram changes nor left ventricular (LV) asynergy
suggesting myocardial ischemia. Aortic root angiography
showed significant PVL (Fig. 1d, Supplementary video 2)
and simultaneous recording of the LV and aortic pressuresrevealed an increased LV end-diastolic pressure up to thelevel of systemic diastolic pressure (Fig. 1e). Before theTAVR, an abnormal relaxation pattern in transmitral Doppler waveform was observed and LV end-diastolic pressure

was 8 mmHg, which could exclude severe LV diastolic dysfunction. Accordingly, the PVL was judged as severe and theequalization of the LV and systemic pressure was thought
to be the cause of reduced leakage at end-diastole. Becauseof high risk of annulus rupture due to a protruding LV outflow tract calcification and the PVL was expected to reducewith gradual valve expansion, post-dilation was deferred.
Postoperative echocardiography after the TAVR showeda reduction to moderate to severe PVL (Fig. 1f, g) based
on VARC-3 criteria [1] with pressure half-time of 349 ms(Fig. 1h). She was finally transferred to another hospital witha blood pressure of 131/48 mmHg and no symptoms.
Because of the equalization of diastolic LV and systemicpressures in severe PVL, we need to avoid underestimation
when PVL vanishing at end-diastole was observed. Comprehensive hemodynamic and angiographic assessment is
mandatory for precise grading of the PVL severity.

Yoji Tamaki and Shingo Tsujinaga equally contributed to thiswork.
* Hiroyuki Iwano
h-iwano@med.hokudai.ac.jp
1

Department of Cardiovascular Medicine, Facultyof Medicine and Graduate School of Medicine, Hokkaido
University, Kita‑15, Nishi‑7, Kita‑ku, Sapporo, Japan13Vol.:(0123456789)

Journal of Echocardiography

Fig. 1  Transesophageal echocardiographic images at early-diastole(a), mid-diastole (b), and end-diastole (c). Yellow arrows on electrocardiogram indicate the phase of the still images. Aortic root angiography with contrast volume of 20 mL (d). Simultaneous recordingof left ventricular and aortic pressures (e). Postoperative transthoracic
echocardiography (f, g) and continuous wave Doppler image of paravalvular leak (h)Supplementary Information The online version contains supplementary material available at https://d​ oi.o​ rg/1​ 0.1​ 007/s​ 12574-0​ 21-0​ 0553-6.

experimentation (institutional and national) and with the Helsinki Declaration of 1964 and later versions.

Author contributions Concept/design: YT, ST, and HI; managementof the patient, data collection, interpretation of the results, and drafting article: KK, TN, and TA; counsel about the discussion section andcritical revision of article. All the authors have read and approved thefinal manuscript.

Informed consent Informed consent was obtained from the patient forbeing included in the study.

Funding None.

Reference

Declarations

1. Varc Writing C, Genereux P, Piazza N, et al. Valve academic
research consortium 3: updated endpoint definitions for aortic
valve clinical research. Eur Heart J. 2021;42:1825–57.

Conflict of interest Yoji Tamaki, Shingo Tsujinaga, Hiroyuki Iwano,Kiwamu Kamiya, Toshiyuki Nagai and Toshihisa Anzai declare thatthey have no conflict of interest.

Publisher's Note Springer Nature remains neutral with regard tojurisdictional claims in published maps and institutional affiliations.

Human rights statements All the procedures followed were in accordance with the ethical standards of the responsible committee on human13