Mitral Valve Peravalvular Mitral Valve Peravalvular (Periprosthetic) Leak(Periprosthetic) Leak

Incidence of Mitral Valve Incidence of Mitral Valve Peravalvular LeakPeravalvular Leak

Reported frequency of 1.2-12.5% after Reported frequency of 1.2-12.5% after mitral valve replacement mitral valve replacement

Presenting symptomsPresenting symptoms– 73.3% heart failure73.3% heart failure– 16.2 % hemolysis16.2 % hemolysis– 10.3%no symptoms10.3%no symptoms

Surgical resultsSurgical results– 40-60% of peravalvular leaks could be repaired 40-60% of peravalvular leaks could be repaired

primarily without replacement of valveprimarily without replacement of valve

  Jacobs et al 1994Jacobs et al 1994

116 mitral valve surgeries (46 MV, 57 116 mitral valve surgeries (46 MV, 57 MV/CABG, 13 MV/AVR)MV/CABG, 13 MV/AVR)

8 patients with MV peravalvular regurgitation 8 patients with MV peravalvular regurgitation 2/8 moderate 2/8 moderate

– both progressed to severe at 18 monthsboth progressed to severe at 18 months 6/8 mild: 6/8 mild:

– 2/6 increased from mild to moderate2/6 increased from mild to moderate– one with CHF treated medicallyone with CHF treated medically– other symptom freeother symptom free

Jacobs et al 1994Jacobs et al 1994

Conclusion:Conclusion:– Moderate peravalvular leak should be Moderate peravalvular leak should be

corrected at time of valve replacement if can corrected at time of valve replacement if can be performed without high operative risk.be performed without high operative risk.

– Mild peravalvular leak should probably also Mild peravalvular leak should probably also be corrected if low risk and surgeon be corrected if low risk and surgeon believes high likelihood of successbelieves high likelihood of success

– Serial follow-up of peravalvular leak is Serial follow-up of peravalvular leak is important.important.

Plehn et al 2001Plehn et al 2001

Found that people did well Found that people did well with trivial or mild with trivial or mild peraprosthetic regurgitation.peraprosthetic regurgitation.

Risk factors for MV Risk factors for MV Peravalvular LeakPeravalvular Leak

StrongStrong– EndocarditisEndocarditis

– Annular calcificationAnnular calcification   Less Strong Less Strong

– Dilated cardiomyopathy.Dilated cardiomyopathy.

– Ischemic mitral regurgitationIschemic mitral regurgitation

    Leak locationLeak location

Pathologic: Pathologic: – in region of high calcificationin region of high calcification

– in region of endocarditis/abscessin region of endocarditis/abscess   Physiologic stress .Physiologic stress .

– Found occurring more commonly in Found occurring more commonly in anterolateral and posteromedial anterolateral and posteromedial portion of the mitral annulusportion of the mitral annulus

  Echocardiographers role:Echocardiographers role:

–Define risk factors; annular Define risk factors; annular calcium, infectioncalcium, infection

–Search diligently for peravalvular Search diligently for peravalvular leak post valve replacement.leak post valve replacement.

–Define location and severity. Define location and severity.

Case #1

Mitral Valve Peravalvular Leak

NA7

Case #2Mitral Valve Peravalvular Leak

78 yr old woman presenting with severe Mitral Regurgitation.

5 years prior, patient declined recommendation for repair.

On following echoes note severe mitral annular calcification.

Surgeon notified of risk of peravalvular leak secondary to calcification.

2

5

8

49

Post BypassPost Bypass

Status post placement bioprosthetic mitral Status post placement bioprosthetic mitral valve valve

Note small peravalvular leak at anterior Note small peravalvular leak at anterior lateral portion of posterior mitral annuluslateral portion of posterior mitral annulus

Note use of altering Nyquist to define locationNote use of altering Nyquist to define location Surgeon had optimized number and Surgeon had optimized number and

technique of annular stitches based on technique of annular stitches based on prebypass echo exam. Decision to accept prebypass echo exam. Decision to accept surgical result.surgical result.

78

83

84

68

64

63

  Reference:Reference:1)1) Movsowitz, Jacobs et al: Long-term Follow-up of Mitral Paraprosthetic Movsowitz, Jacobs et al: Long-term Follow-up of Mitral Paraprosthetic

Regurgitation by Transesophageal Echocardiography. J Am Soc Echocardiogr Regurgitation by Transesophageal Echocardiography. J Am Soc Echocardiogr 1994;488-92.1994;488-92.

2)2) O'Rourke, Plehn et al: Outcome of Mild Periprosthetic Regurgitation Detected O'Rourke, Plehn et al: Outcome of Mild Periprosthetic Regurgitation Detected by Intraoperative Transesophageal Echocardiography. J Am Coll Cardiol by Intraoperative Transesophageal Echocardiography. J Am Coll Cardiol 2001;38:163-6.2001;38:163-6.

3)3) De Cicco, Lorusso: Mitral valve periprosthetic leakage: anatomical observations De Cicco, Lorusso: Mitral valve periprosthetic leakage: anatomical observations in 135 patients from a multicentre study. Europ J Cardio Thorac Surg: 30 in 135 patients from a multicentre study. Europ J Cardio Thorac Surg: 30 (2006) 887-891.(2006) 887-891.

4)4) Akins, MacGillivray: Early and Late Results of the Surgical Correction of Akins, MacGillivray: Early and Late Results of the Surgical Correction of Cardiac Prosthetic Paravavlular Leaks. J Heart Valve Dis 2005;14:792-800.Cardiac Prosthetic Paravavlular Leaks. J Heart Valve Dis 2005;14:792-800.

5)5) Dhasmana, Kirklin, Kouchoukos. Factors Associated With Periprosthetic Dhasmana, Kirklin, Kouchoukos. Factors Associated With Periprosthetic Leakage Following Primary Mitral Valve Replacement: With Special Leakage Following Primary Mitral Valve Replacement: With Special Consideration of the Suture TechniqueConsideration of the Suture Technique