Prevalence and clinical significance of mild paraprosthetic ring leaks and left atrial spontaneous echo contrast detected on transesophageal echocardiography three months after isolated mitral valve replacement with a mechanical prosthesis

Mitral valve paravalvular leaks: Comprehensive review of literature

BACKGROUND

Mitral paravalvular leaks (mPVL) are a recognized complication for patients with mitral valve prostheses. Although clinically insignificant for many patients, it may pose life-threatening haemolysis and regurgitation-induced heart failure, and so clinicians should have a high index of suspicion in the presence of new symptoms.

AIMS

This review discusses the pathogenesis, clinical features, diagnosis, imaging and treatment of mPVLs.

METHODS

A comprehensive literature search was performed using PubMed, EMBASE, Cochrane database, Google Scholar and Ovid. Search terms used included "mitral valve paravalvular leak," "transthoracic echocardiography," "2D transoesophageal echocardiography," "3D transoesophageal echocardiography," "cardiac computed tomography," (CT) "cardiac magnetic resonance imaging," "intracardiac echocardiography," "cinefluoroscopy," "fluoroscopy," and "percutaneous closure."

RESULTS

All patients with mPVLs should undergo regular full evaluation, including patient history, physical examination, laboratory work-up, imaging, and referral, if necessary. Echocardiography is fundamental to the diagnosis, and is augmented with cardiac magnetic resonance imaging, cardiac computerized tomography and fluoroscopy for further characterization and procedural planning amongst the structural heart team.

CONCLUSION

The prevalence of mPVL is expected to increase proportionally to the growing number of surgical and transcatheter valve replacements conducted in the ageing population. Multimodal imaging is instrumental in guiding diagnostic and therapeutic strategies when managing mPVLs. Advances in imaging and capabilities of transcather devices will prompt growing uptake of percutaneous treatment over conventional, higher-risk surgery for mPVL management.

Percutaneous Device Closure of Paravalvular Leak: Combined Experience From the United Kingdom and Ireland

BACKGROUND

Paravalvular leak (PVL) occurs in 5% to 17% of patients following surgical valve replacement. Percutaneous device closure represents an alternative to repeat surgery.

METHODS

All UK and Ireland centers undertaking percutaneous PVL closure submitted data to the UK PVL Registry. Data were analyzed for association with death and major adverse cardiovascular events (MACE) at follow-up.

RESULTS

Three hundred eight PVL closure procedures were attempted in 259 patients in 20 centers (2004-2015). Patient age was 67±13 years; 28% were female. The main indications for closure were heart failure (80%) and hemolysis (16%). Devices were successfully implanted in 91% of patients, via radial (7%), femoral arterial (52%), femoral venous (33%), and apical (7%) approaches. Nineteen percent of patients required repeat procedures. The target valve was mitral (44%), aortic (48%), both (2%), pulmonic (0.4%), or transcatheter aortic valve replacement (5%). Preprocedural leak was severe (61%), moderate (34%), or mild (5.7%) and was multiple in 37%. PVL improved postprocedure (P<0.001) and was none (33.3%), mild (41.4%), moderate (18.6%), or severe (6.7%) at last follow-up. Mean New York Heart Association class improved from 2.7±0.8 preprocedure to 1.6±0.8 (P<0.001) after a median follow-up of 110 (7-452) days. Hospital mortality was 2.9% (elective), 6.8% (in-hospital urgent), and 50% (emergency) (P<0.001). MACE during follow-up included death (16%), valve surgery (6%), late device embolization (0.4%), and new hemolysis requiring transfusion (1.6%). Mitral PVL was associated with higher MACE (hazard ratio [HR], 1.83; P=0.011). Factors independently associated with death were the degree of persisting leak (HR, 2.87; P=0.037), New York Heart Association class (HR, 2.00; P=0.015) at follow-up and baseline creatinine (HR, 8.19; P=0.001). The only factor independently associated with MACE was the degree of persisting leak at follow-up (HR, 3.01; P=0.002).

CONCLUSION

Percutaneous closure of PVL is an effective procedure that improves PVL severity and symptoms. Severity of persisting leak at follow-up is independently associated with both MACE and death. Percutaneous closure should be considered as an alternative to repeat surgery.

[Prognosis of periprosthetic regurgitation after mitral valve replacement using the Saint Jude prosthesis]

Periprosthetic regurgitation (PPR) is a common complication of mitral valve replacement (MVR). The management of moderate and minor PPR remains controversial. The goal of this prospective study was to determine the incidence, predictors and outcome of PPR discovered using omniplan transoesophageal echocardiography (TEE) performed at the early postoperative period (14.7 days) of MVR with SJM prosthesis. Our study enrolled 56 patients, the mean age was 44.5 +/- 11.9 years. The incidence of PPR was 59% (33 patients). TEE showed one jet in nine patients (27%), two jets in 23 patients (70%) and three jets in one patient (3%). PPR is minor in 24 patients (63%) and moderate in nine patients (27%). No patient developed hemolytic anemia or congestive heart failure. In univariate analysis, diameter of prostheses > 27 mm, number of suture knots < 17 and diameter of prostheses/number of knot ratio > 1.7 independently predicted the presence of PPR. In multivariate analysis only a rapport diameter of protheses/number of suture knots > 1.7 mm is predictif of PPR (odd ratio = 9, P = 0.036). Ninety percent of PPR remained present at six weeks and only 29% were present after 12.5 months.

CONCLUSION

Mild and minor PPR were frequent during the early postoperative period after MVR. The clinical significance and natural history is benign and they do not require any specific treatment.

Prevalence and clinical significance of incidental paraprosthetic valvar regurgitation: a prospective study using transoesophageal echocardiography

OBJECTIVE

To assess the prevalence, mechanisms, and significance of paraprosthetic regurgitation detected incidentally by transoesophageal echocardiography (TOE) in patients after heart valve replacement.

DESIGN

Prospective observational study.

SETTING

Tertiary referral centre.

PATIENTS

360 consecutive patients (mean (SD) age 65.8(9.5) years, 193 women) undergoing elective first ever valve replacement.

METHODS

Postoperative and follow up TOE, and tests for haemolysis and anaemia.

RESULTS

There were 243 aortic, 90 mitral, and 27 double valve replacements, using 316 mechanical and 44 tissue valves, giving 270 aortic and 117 mitral valves. One patient with severe paraprosthetic mitral regurgitation underwent immediate reoperation and was excluded from subsequent analyses. Paraprosthetic jets were detected around 16 (6%) of the aortic and 38 (32%) of the mitral valves (p < 0.05) at the postoperative study. Follow up TOE was available for 151 aortic and 67 mitral valves, 0.9 (0.5) years after operation. Paraprosthetic jets were present in 15 (10%) of the aortic and 10 (15%) of the mitral valves (NS). Two thirds of the aortic and a fifth of the mitral jets were new. Paraprosthetic jets were more common in aortic valves in a supra-annular (12 of 88, 14%) than in an intra-annular position (4 or 182, 2%; p < 0.005) and in mitral valves inserted with continuous (36 of 88, 41%) rather than interrupted sutures (2 of 28, 7%; p < 0.001). Lactate dehydrogenase concentration was higher in patients with paraprosthetic jets than in those without (752 (236) v 654 (208) IU/l, p < 0.001). Haemoglobin and haptoglobin concentrations were not different.

CONCLUSIONS

Small paraprosthetic leaks are common, are related to surgical factors, are not associated with increased subclinical haemolysis, and are benign during the first year after heart valve replacement.

Intraoperative echocardiographic detection of regurgitant jets after valve replacement

BACKGROUND

Paravalvular jets, documented by intraoperative transesophageal echocardiography, have prompted immediate valve explantation by others, yet the significance of these jets is unknown.

METHODS

Twenty-seven patients had intraoperative transesophageal two-dimensional color Doppler echocardiography, performed to assess the number and area of regurgitant jets after valve replacement, before and after protamine. Patients were grouped by first time versus redo operation, valve position and type.

RESULTS

Before protamine, 55 jets were identified (2.04+/-1.4 per patient) versus 29 jets after (1.07+/-1.2 per patient, p = 0.0002). Total jet area improved from 2.0+/-2.2 cm2 to 0.86+/-1.7 cm2 with protamine (p<0.0001). In all patients jet area decreased (average decrease, 70.7%+/-27.0%). First time and redo operations had similar improvements in jet number and area (both p>0.6). Furthermore, mitral and mechanical valves each had more jets and overall greater jet area when compared to aortic and tissue valves, respectively.

CONCLUSIONS

Following valve replacement, multiple jets are detected by intraoperative transesophageal echocardiography. They are more common and larger in the mitral position and with mechanical valves. Improvement occurs with reversal of anticoagulation.

Predictors of left atrial thrombus and spontaneous echo contrast in rheumatic valve disease before and after mitral valve replacement

In this study we aimed to analyze, with reference to mitral regurgitation (MR), the incidence and predictors of left atrial (LA) thrombus and spontaneous echo contrast in patients with rheumatic valve disease before and after mitral valve replacement. The incidence of LA thrombus is known to be less in patients with MR. The impact of mitral valve replacement on this beneficial effect has not been studied in detail. The study included 169 consecutive patients (59 men and 110 women, average age 40 +/- 13 years) with rheumatic mitral valve disease who underwent transesophageal echocardiographic examination 1 to 3 days before and within 7 days (mean 4.0 +/- 1.3) after mitral valve replacement using mechanical prostheses in a single institution. The preoperative incidence of echocardiographic LA spontaneous echo contrast (SEC) was 1.1%, 30%, and 54%, and the incidence of thrombus was 1.1%, 13%, and 17% in the groups with MR, combined mitral stenosis + MR, and isolated mitral stenosis, respectively. In the MR group, SEC and thrombus incidence increased significantly after surgery. The independent predictors for postoperative thrombus development were atrial fibrillation, postoperative SEC, and preoperative thrombus. Thrombus recurred after surgery in 64% of 14 patients who had surgical thrombectomy. The presence of postoperative MR was associated with decreased risk of postoperative SEC and thrombus development. The interaction between MR and SEC and thrombus both before and after surgery provides further support for the protective effect of MR against LA thrombus formation.

Transesophageal echocardiography

This article presents an overview of the benefits and efficacy of transesophageal echocardiography (TEE) in the critically ill patient. The echocardiographic evaluation of ventricular function both regional and global, is discussed with special emphasis on ischemic heart disease; assessment of preload, interrogation of valvular heart disease (prosthetic and native) and its complications; endocarditis and its complications; intracardiac and extracardiac masses, including pulmonary embolism; aortic diseases (e.g., aneurysan, dissection, and traumatic tears); evaluation of patent foramen ovale and its association with central and peripheral embolic events; advancements in computer technology; and finally, the effect of TEE on critical care.