Pathophysiology, diagnosis, and management of hemolysis in patients with prosthetic valve related paravalvular leaks.

Paravalvular leak (PVL) is a recognized complication after prosthetic valve implantation, occurring in up to 17% of cases. While small leaks are often clinically silent, moderate or severe PVLs may result in significant hemolysis or heart failure. Hemolysis is driven by turbulent flow through the defect, leading to red blood cell fragmentation. Laboratory features include anemia, elevated lactate dehydrogenase, low haptoglobin, indirect hyperbilirubinemia, and schistocytes on peripheral smear. Diagnosis relies primarily on echocardiography, with transesophageal imaging providing superior sensitivity. Cardiac computed tomography may be helpful in complex or recurrent cases. Management depends on symptom burden and hemolytic severity. Conservative therapy with transfusions, iron and folate supplementation, or beta-blockade may stabilize mild cases, but persistent hemolysis or heart failure generally requires intervention. Redo surgery offers definitive repair but carries high operative risk, particularly in patients with comorbidities. In recent years, transcatheter PVL closure has emerged as a less invasive alternative, with high procedural success and improvement in hematologic and clinical outcomes, although residual leakage remains a limitation. Long-term prognosis is determined by early recognition and individualized treatment. A multidisciplinary heart team approach is essential, and future research should refine patient selection and improve closure outcomes.