Aortic Paravalvular Leaks. The Role Of Intraoperative Transesophageal Echocardiography In Diagnosis And Correction Guidance

Abstract

Objective: Paravalvular leak (PVL) is a known and undesirable complication of prosthetic valve replacement. The presence of significant PVL is associated with comorbidities such as hemolysis, heart failure, and decreased long-term survival. The role of intraoperative transesophageal echocardiography (IOTEE) is the standard of care for valve repair surgery. However, its use in valve replacement is not universal. Methods: We performed a retrospective analysis of Aortic Valve Replacement (AVR) surgeries with IOTEE, from 2018-2020. Primary outcomes were the incidence of intraoperative PVL pre and post echocardiography guided correction. Secondary outcomes were PVL predictors factors, cardiopulmonary bypass time and cross clamp time. PVL was defined, according to circumferential extent of the regurgitant jet, as mild (<10%), moderate (10-20%) and severe (>20%). A PVL greater than mild was considered significant. Results: A total of 194 patients underwent surgical AVR (table 1); 73(37.6%) underwent minimally invasive aortic valve replacement and 121(62.4%) conventional aortic valve replacement. Of them, 87(4.8%) were isolated AVR and 107(55.1%) combined procedures. The overall incidence of significant PVL was 2.6% (n=5). All of them underwent echocardiography guided correction. Post correction IOTEE showed none significant PVL. Mild PVL was diagnosed in four of them. Cardiopulmonary bypass time was 119±37.9 minutes and cross clamp time was 81±26.1 minutes. There were no significant differences in these times between patients with PVL that needed correction and patients who did not. Diagnosis, etiology, bicuspid aortic valve, type of prosthesis and size number were not associated with PVL incidence. Conclusions: IOTEE allows early diagnosis of PVL. This enables intraoperative correction, without significant extension of surgical times, resulting in non-significant PVL. IOTEE should be the standard of care in AVR surgery. Table 1. Patients characteristics Patients n 194 Age (Mean±SD) 69.9 ± 11.4 Sex n (%) Male, Female 113(58.2%), 81(41.8) Diagnosis n (%)Aortic StenosisAortic InsufficiencyConcomitant stenosis and insufficiencyInfectious Endocarditis 146 (76%)28 (14.6%)16 (8.3%)2 (1%) Etiology n (%)CalcificationRheumatic diseaseAnulectasisProlapseInfectious EndocarditisProsthetic DysfunctionFibroelastomaOthers 160 (82.5%)3 (1.5%)6 (3.1%)10 (5.2%)6 (3.1%)2 (1%)2 (1%)5 (2.6%) Bicuspid valve n (%) 31 (16.1%) NYHA Functional Class n (%)No Heart failureIIIIIIIV 24 (13.6%)10 (5.6%)112 (63.3%)29 (16.4%)2 (1.1%) Angina 76 (40.9%) Left Ventricle Ejection Fraction (LVEF) n (%)Normal>50%30-50%<30% 143 (76.5)18 (9.6%)11 (5.9%)15 (8%) Euro Score II n (%)Low RiskIntermediate RiskHigh Risk 173 (89.6%)19 (9.8%)1 (0.5%)