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Published on: December 11, 2017
Characteristics and longer-term outcomes of paravalvular leak after aortic and mitral valve surgery
Shailee Shah1, Alaa Alashi1, Gosta B Pettersson1
1Valve Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
Background:
Paravalvular leak (PVL) is often seen after aortic (AV) and mitral valve (MV) surgery, either due to infection or valve dehiscence. We sought to describe predictors of longer-term outcomes in patients who developed PVL after AV and MV surgery and were considered eligible for reoperative cardiac surgery (RCS).
Methods:
We studied 495 such patients (65 ± 14 years, 65% men, 47% with MV PVL) who presented at our center between January 2003 and December 2011. Patients with severe mitral/aortic stenosis, patients with less than mild PVL, and those with prohibitive risk precluding RCS were excluded. Society of Thoracic Surgeons (STS) score was calculated. Primary endpoint was mortality.
Results:
At baseline, mean STS score and left ventricular ejection fraction were 5.8 ± 4% and 52 ± 12%, respectively. In total, 105 (21%) had infective PVL and 72% had moderate or greater PVL. At a median of 8 days, 351 (71%) patients underwent RCS to repair PVL (3% in-hospital postoperative mortality), and at 6.6 ± 4 years, 230 (47%) patients died. On multivariable Cox survival analysis, greater STS score (hazard ratio or HR 1.35), mitral versus aortic PVL (HR 1.66), infectious etiology (HR 2.05), and greater right ventricular systolic pressure (HR 1.09) were associated with greater longer-term mortality, whereas surgery (HR 0.58) was associated with improved longer-term survival (all P < .05).
Conclusions:
Patients who develop mild or greater PVL after AV/MV surgery have a high rate of longer-term mortality, despite excellent perioperative outcomes. Greater STS score, right ventricular systolic pressure, infectious etiology, and MV (vs AV) involvement were all independently associated with long-term mortality, whereas RCS for PVL closure was associated with improved longer-term survival.
Insights
Paravalvular leak (PVL) after valve surgery is linked to high long-term mortality. Predictors include higher STS score, mitral PVL, and infection, while reoperative cardiac surgery improves survival.
Area of Science:
- Cardiology
- Cardiac Surgery
- Medical Research
Background:
- Paravalvular leak (PVL) is a common complication following aortic (AV) and mitral valve (MV) surgery.
- PVL can result from infection or valve dehiscence, impacting long-term patient outcomes.
- Identifying predictors of outcomes in patients eligible for reoperative cardiac surgery (RCS) is crucial.
Purpose of the Study:
- To identify predictors of longer-term mortality in patients with PVL after AV or MV surgery.
- To evaluate the impact of reoperative cardiac surgery (RCS) on survival in this patient cohort.
- To analyze factors associated with increased mortality following PVL development.
Main Methods:
- A cohort of 495 patients with PVL after AV/MV surgery, eligible for RCS, was studied.
- Exclusion criteria included severe valve stenosis, less than mild PVL, and prohibitive surgical risk.
- Data collected included Society of Thoracic Surgeons (STS) score, ejection fraction, and PVL characteristics; primary endpoint was mortality.
Main Results:
- The mean STS score was 5.8±4%, with 21% having infective PVL and 72% moderate or greater PVL.
- 71% of patients underwent RCS with 3% in-hospital mortality; 47% died during long-term follow-up (median 6.6 years).
- Multivariable analysis identified higher STS score, mitral PVL, infectious etiology, and elevated right ventricular systolic pressure as mortality predictors (all P < .05).
Conclusions:
- Mild or greater PVL after AV/MV surgery is associated with significant long-term mortality despite good perioperative results.
- Higher STS score, elevated right ventricular systolic pressure, infectious etiology, and mitral PVL independently predict long-term mortality.
- Reoperative cardiac surgery for PVL closure was associated with improved longer-term survival.
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