Revista espanola de cardiologia | 2019
Percutaneous management of paravalvular leaks: an alternative to surgery or first-line therapy.
Abstract
Paravalvular leaks (PVLs) are abnormal communications between the valvular prosthesis sewing ring and the surrounding cardiac tissue (figure 1). Although most PVLs are clinically insignificant, it is estimated that between 2% and 5% cause congestive heart failure, hemolytic anemia, or both. Traditionally, surgery has been the only corrective treatment for PVLs. Indeed, it is still considered the technique of choice because it improves survival and reduces symptoms in patients with significant PVL vs conservative treatment. Surgical options include PVL repair or prosthesis replacement. The type of surgery depends on the size and extent of the PVL, the condition of the native valve ring, and the patient’s surgical history. Nonetheless, regardless of the technique used, reoperation due to PVL is associated with a higher risk of mortality and morbidity than the first surgery, particularly for mitral valve interventions. In addition, after repeated operations, there is a considerable risk of PVL recurrence due to persistent calcification or underlying tissue friability. Since Hourihan first described the procedure in 1992, interest has continually grown in the use of transcatheter techniques to treat PVL. These approaches were initially reserved as an alternative to medical treatment for inoperable patients or patients with high surgical risk but many experienced centers have recently adopted percutaneous techniques as first-line therapy for patients with PVL. Until a few years ago, the global scientific evidence regarding these techniques was limited to single-center studies without long-term clinical follow-up. However, the national registries of Spain and the United Kingdom and Ireland have recently been published, as well as several studies comparing the outcomes of surgical treatment and transcatheter techniques. Their findings are summarized below. Millán et al. performed a Bayesian meta-analysis including 12 studies and 362 patients with PVL treated with transcatheter techniques. Most of the procedures (70%) were performed on mitral PVL. Procedural success—defined as release of the closure device without prosthesis interference and a reduction of at least 1 grade in the regurgitation severity—was observed in 76.5% of patients, with a slightly lower success rate for mitral procedures than for aortic procedures (73.3% vs 84.1%). Compared with the failed procedures, successful percutaneous management of PVLs was associated with lower cardiac mortality (odds ratio [OR] = 0.08; 95% credibility interval [95%CrI], 0.010.90), a greater improvement in New York Heart Association (NYHA) functional class or hemolysis (OR = 9.95; 95%CrI, 2.1-66.7), and less need for reoperation (OR = 0.08; 95%CrI, 0.01-0.40).