Mitral Valve Peravalvular (Periprosthetic) Leak

Incidence of Mitral Valve Peravalvular Leak u Reported frequency of % after mitral valve replacement u Presenting symptoms –73.3% heart failure –16.2 % hemolysis –10.3%no symptoms u Surgical results –40-60% of peravalvular leaks could be repaired primarily without replacement of valve

Jacobs et al 1994 Jacobs et al 1994 u 116 mitral valve surgeries (46 MV, 57 MV/CABG, 13 MV/AVR) u 8 patients with MV peravalvular regurgitation u 2/8 moderate –both progressed to severe at 18 months u 6/8 mild: –2/6 increased from mild to moderate –one with CHF treated medically –other symptom free

Jacobs et al 1994 u Conclusion: –Moderate peravalvular leak should be corrected at time of valve replacement if can be performed without high operative risk. –Mild peravalvular leak should probably also be corrected if low risk and surgeon believes high likelihood of success –Serial follow-up of peravalvular leak is important.

Plehn et al 2001 u Found that people did well with trivial or mild peraprosthetic regurgitation.

Risk factors for MV Peravalvular Leak u Strong –Endocarditis –Annular calcification u Less Strong –Dilated cardiomyopathy. –Ischemic mitral regurgitation

Leak location Leak location u Pathologic: –in region of high calcification –in region of endocarditis/abscess u Physiologic stress. –Found occurring more commonly in anterolateral and posteromedial portion of the mitral annulus

Echocardiographers role: Echocardiographers role: –Define risk factors; annular calcium, infection –Search diligently for peravalvular leak post valve replacement. –Define location and severity.

Case #1 Mitral Valve Peravalvular Leak

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Case #2 Mitral Valve Peravalvular Leak u u 78 yr old woman presenting with severe Mitral Regurgitation. u u 5 years prior, patient declined recommendation for repair. u u On following echoes note severe mitral annular calcification. u u Surgeon notified of risk of peravalvular leak secondary to calcification.

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Post Bypass u Status post placement bioprosthetic mitral valve u Note small peravalvular leak at anterior lateral portion of posterior mitral annulus u Note use of altering Nyquist to define location u Surgeon had optimized number and technique of annular stitches based on prebypass echo exam. Decision to accept surgical result.

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Reference: 1) Movsowitz, Jacobs et al: Long-term Follow-up of Mitral Paraprosthetic Regurgitation by Transesophageal Echocardiography. J Am Soc Echocardiogr 1994; ) O'Rourke, Plehn et al: Outcome of Mild Periprosthetic Regurgitation Detected by Intraoperative Transesophageal Echocardiography. J Am Coll Cardiol 2001;38: ) De Cicco, Lorusso: Mitral valve periprosthetic leakage: anatomical observations in 135 patients from a multicentre study. Europ J Cardio Thorac Surg: 30 (2006) ) Akins, MacGillivray: Early and Late Results of the Surgical Correction of Cardiac Prosthetic Paravavlular Leaks. J Heart Valve Dis 2005;14: ) Dhasmana, Kirklin, Kouchoukos. Factors Associated With Periprosthetic Leakage Following Primary Mitral Valve Replacement: With Special Consideration of the Suture Technique