title: Paravalvular leakage after mitral valve replacement: improved long-term survival with aggressive surgery?
abstract: BACKGROUND
  Following mitral valve replacement, surgical closure of paravalvular leaks is usually advised in severely symptomatic patients and in those requiring blood transfusions for persisting haemolysis. However, the long-term prognosis of less symptomatic patients or those not needing blood transfusions is unknown.
  
  
  METHODS
  Between 1987 and 1997, we observed 96 patients with mitral paravalvular leakage. A paraprosthetic leak was diagnosed after a median time of 119 days (range: 1 day-23 years) after primary mitral valve replacement. During an average follow-up of 5 years (range: 1-23 years), 50/96 patients were referred for surgical closure.
  
  
  RESULTS
  Compared with patients who received conservative treatment, those referred for surgery had a significantly lower mean preoperative haematocrit (P = 0.002) with a higher proportion of patients being in the NYHA class III/IV (P = 0.03). Age, gender, left ventricular function and number and size of leaks did not differ between the groups. The 30-day postoperative mortality for valve reoperation was 6% (3/50); during follow-up three further patients died, resulting in an overall mortality rate of 12%. In the group treated conservatively there was a mortality rate of 26% (12/46). Thus, the actuarial survival for patients referred for surgery was 98, 90 and 88% after 1, 5 and 10 years, compared with 90, 75 and 68% for patients treated conservatively (long-rank P = 0.03). In addition, there was a significant increase in mean haematocrit levels (P = 0.0001) and an improvement in NYHA class III/IV symptoms (P = 0.002), vertigo (P = 0.001) and fatigue (P = 0.001) after surgery.
  
  
  CONCLUSIONS
  Following mitral valve replacement, a more aggressive surgical treatment is recommended for patients with paraprosthetic leaks. Surgery should be offered to less symptomatic patients, as well as those not requiring blood transfusion.
authors.affiliation: Division of Cardiac Surgery, University Hospital, Zurich, Switzerland. michele.genoni@triemli.stzh.ch
authors.forename: M
authors.initials: M
authors.lastname: Genoni
authors.forename: D
authors.initials: D
authors.lastname: Franzen
authors.forename: P
authors.initials: P
authors.lastname: Vogt
authors.forename: B
authors.initials: B
authors.lastname: Seifert
authors.forename: R
authors.initials: R
authors.lastname: Jenni
authors.forename: A
authors.initials: A
authors.lastname: Künzli
authors.forename: U
authors.initials: U
authors.lastname: Niederhäuser
authors.forename: M
authors.initials: M
authors.lastname: Turina
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001672:Biocompatible Materials; D017548:Echocardiography, Transesophageal; D005260:Female; D005500:Follow-Up Studies; D006350:Heart Valve Prosthesis; D019918:Heart Valve Prosthesis Implantation; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D008943:Mitral Valve; D008944:Mitral Valve Insufficiency / Q000000981:diagnostic imaging / Q000453:epidemiology / Q000209:etiology / Q000601:surgery*; D011379:Prognosis; D011475:Prosthesis Failure; D012086:Reoperation; D012189:Retrospective Studies; D011795:Surveys and Questionnaires; D015996:Survival Rate; D013557:Switzerland / Q000453:epidemiology
chemical_list: D001672:Biocompatible Materials