Paravalvular leakage after mitral valve replacement: improved long-term survival with aggressive surgery?

• Published in: European journal of cardio-thoracic surgery Vol. 17; no. 1; pp. 14 - 19
• Main Authors: Genoni, Michele, Franzen, Daniel, Vogt, Paul, Seifert, Burkhardt, Jenni, Rolf, Künzli, Andreas, Niederhäuser, Urs, Turina, Marko
• Format: Journal Article
• Language: English
• Published: Germany Elsevier Science B.V 01.01.2000
• Subjects: Adult; Aged; Aged, 80 and over; Biocompatible Materials; Echocardiography, Transesophageal; Female; Follow-Up Studies; Heart Valve Prosthesis; Heart Valve Prosthesis Implantation; Humans; Incidence; Male; Middle Aged; Mitral Valve; Mitral Valve Insufficiency - diagnostic imaging; Mitral Valve Insufficiency - epidemiology; Mitral Valve Insufficiency - etiology; Mitral Valve Insufficiency - surgery; Mitral valve replacement; Paravalvular leaks; Prognosis; Prosthesis Failure; Reoperation; Retrospective Studies; Surgery; Surveys and Questionnaires; Survival; Survival Rate; Switzerland - epidemiology; Paravalvular leaks; Survival; Surgery; Mitral valve replacement
• ISSN: 1010-7940; 1873-734X
• DOI: 10.1016/S1010-7940(99)00358-9

Background: Following mitral valve replacement, surgical closure of paravalvular leaks is usually advised in severely symptomatic patients and in those requiring blood transfusions for persisting haemolysis. However, the long-term prognosis of less symptomatic patients or those not needing blood transfusions is unknown. Methods: Between 1987 and 1997, we observed 96 patients with mitral paravalvular leakage. A paraprosthetic leak was diagnosed after a median time of 119 days (range: 1 day–23 years) after primary mitral valve replacement. During an average follow-up of 5 years (range: 1–23 years), 50/96 patients were referred for surgical closure. Results: Compared with patients who received conservative treatment, those referred for surgery had a significantly lower mean preoperative haematocrit (P=0.002) with a higher proportion of patients being in the NYHA class III/IV (P=0.03). Age, gender, left ventricular function and number and size of leaks did not differ between the groups. The 30-day postoperative mortality for valve reoperation was 6% (3/50); during follow-up three further patients died, resulting in an overall mortality rate of 12%. In the group treated conservatively there was a mortality rate of 26% (12/46). Thus, the actuarial survival for patients referred for surgery was 98, 90 and 88% after 1, 5 and 10 years, compared with 90, 75 and 68% for patients treated conservatively (long-rank P=0.03). In addition, there was a significant increase in mean haematocrit levels (P=0.0001) and an improvement in NYHA class III/IV symptoms (P=0.002), vertigo (P=0.001) and fatigue (P=0.001) after surgery. Conclusions: Following mitral valve replacement, a more aggressive surgical treatment is recommended for patients with paraprosthetic leaks. Surgery should be offered to less symptomatic patients, as well as those not requiring blood transfusion.