LONG-TERM Results FOLLOWING SURGICAL TREATMENT OF PARAVALVULAR LEAK IN THE AORTIC AND MITRAL POSITION

Abstract

Periprosthetic leak (PPL) is the most common non-structural prosthesis dysfunction following heart valve replacement. Symptomatic PPL requires reintervention. However, there is a paucity of data regarding outcomes after surgical treatment of PPL. The aim of this study was to determine immediate results and long-term outcomes following surgical management of aortic and/or mitral PPL. Between 1995 and 2012, 214 patients underwent primary surgical repair (n=148) or valve replacement (n=66) for an aortic and/or mitral PPL at our institution. Of these, 128 (60%) had PPL in the mitral position, 77 (36%) had PPL in the aortic position and 9 (4%) had PPL on both valves. Mean follow-up was 5.3 ± 4.6 years. Seventeen (8%) patients were lost to follow-up after surgery. Mean age at surgery was 62 ± 12 years and 128 (60%) patients were male. Primary indication for surgery was congestive heart failure in 91 (71%) patients with mitral PPL, 65 (84%) patients with aortic PPL and 5 (56%) patients with double valve PPL. Other indications included severe hemolysis in 34 (16%) patients and endocarditis in 4 (2%) patients. The most frequent site of mitral PPL was at the posteromedian commissure and the most common site for aortic PPL was the non-coronary sinus. Operative mortality occurred in 9 (4%) patients (6 [5%] in mitral, 2 [3%] in aortic and 1 [14%] in double valve repairs). Survival at 1, 5 and 10 years was 88 ± 2%, 74 ± 3% and 60 ± 5%, respectively. Freedom from NYHA ≥ III was 93 ± 3%, 79 ± 6 % and 58 ± 8% at 1, 5 and 10 years, respectively. Freedom from PPL recurrence was 98 ± 2 %, 86 ± 4% and 66 ± 6% at 1, 5 and 10 years respectively. There was a trend towards better freedom from PPL recurrence in patients who underwent primary repair compared to valve replacement, but this difference was not statistically significant (p=0.17). In patients who suffered from PPL recurrence, the new leak occurred in the same location as the previous surgery in 11 (39%) patients. Life expectancy after surgical treatment of PPL is suboptimal. However, the freedom from PPL is acceptable and there is a trend towards better durability with primary repair. This study highlights the need for clearer guidelines for the management of PPL.