Surgical Paravalvular Leak Closure: No More Second Chances

Current Devices and Complications Related to Transcatheter Mitral Valve Replacement: The Bumpy Road to the Top

Mitral regurgitation is the most common valvular lesion in the developed world, with increasing prevalence, morbidity, and mortality. The experience with surgical mitral valve repair or replacement is very well-validated. However, more than 45% of these patients get denied surgery due to an elevated risk profile and advanced disease of the left ventricle at the time of presentation, promoting the need for less invasive transcatheter options such as transcatheter repair and transcatheter mitral valve replacement (TMVR). Early available TMVR studies have shown promising results, and several dedicated devices are under clinical evaluation. However, TMVR is still in the early developmental stages and is associated with a non-negligible risk of periprocedural and post-procedural complications. In this review, we discuss the current challenges facing TMVR and the potential TMVR-related complications, offering an overview on the measures implemented to mitigate these complications, and future implications.

Elective Percutaneous Paravalvular Leak Closure Under Conscious Sedation: Procedural Techniques and Clinical Outcomes

BACKGROUND

Paravalvular leaks (PVLs) are a well-recognized complication of prosthetic valves that are detected up to 18% of all implanted surgical valves. Perioperative morbidity is thought to be lower in percutaneous compared to surgical PVL repair. However, a direct comparison of PVL closure techniques has never been performed. Our study is the first to demonstrate that elective PVL closure with monitored anesthesia care can be achieved with high success and low complications rates resulting in short hospital stays.

METHODS

This is a retrospective cohort of patients admitted electively for catheter-based treatment of symptomatic prosthetic paravalvular regurgitation from Jan 2013 to April 2018. Both mitral and aortic PVLs were included. Patients' demographics, risk factors, procedural outcomes, In-hospital and thirty-day mortality were all reported. We followed the Valve Academic Research Consortium (VARC) criteria to define device and procedural technical success. In-hospital and 30- day outcomes were assessed by retrospective chart review.

RESULTS

A total of 54 PVLs in thirty-seven patients were repaired (65% aortic & 35% mitral). The mean-age in the mitral cohort was lower than the aortic cohort (61 vs 72years, P<0.0001) but the two groups shared similar clinical risk factors (P>0.05). Average hospital stay was 1-2days (<1.5days overall cohort) which was significantly lower in the aortic compared to the mitral cohort (P=0.009). All procedures were guided by TEE under conscious sedation with monitored anesthesia care. Procedural technical success defined as any significant residual shunt was 81% in the overall cohort and 88% in the aortic group. No procedural deaths were reported. Short-term mortality during the first 30days was 5.4% (two patients).

CONCLUSION

Elective catheter-based repair of symptomatic prosthetic paravalvular regurgitation appears to be safe and effective. The use of conscious sedation with monitored anesthesia care resulted in short hospital stay.