Aortic Valve Peravalvular LeakAortic Valve Peravalvular Leak

Risk factors for Aortic Valve Peravalvular Leak

EndocarditisEndocarditis calcified annuluscalcified annulus bicuspid aortic valvebicuspid aortic valve

– Note many present with significant Note many present with significant annular calcificationannular calcification

Marfan SyndromeMarfan Syndrome

Rallidis et al (1999)

Studied 84 consecutive patients with aortic valve replacements Patients studied prospectively at early (11days), Mid

(27months) and late (63 months) intervals.

– 40 patients developed leaks early, 90% of these were small and did not change over time. Patients did well.

 3 patients developed severe paraprosthetic regurgitation late related to endocarditis one patient had degenerative tissue valve failure.

 Concluded: Small leaks usually have a benign course. Development of new severe regurgitation should raise concern of endocarditis or prosthetic valve failure.

 DeCicco et al (2005)

Multi centre study:– 1,696 patients undergoing AVR– 39 (2.3%) with paraprosthetic leak

Symptoms in patients with paraprosthetic leak– 71.4% Heart Failure– 17.8% Hemolysis– 10.8% none

28 people underwent surgery– 20/28 valve replaced– 8/28 Prosthetic leak closed by sutures– surgical mortality 7%

 Role of Echocardiographer Intraoperatively

Preprocedure:– Assess risk factors for Peravalvular leak

annular calcification endocarditis/abscess

Post aortic valve replacement– Diligently search for Peravalvular leak

– Diligently search for fistula into RA/LA/RVOTEspecially focus in areas of heavy calcium or abscess.

 Define location and severity.

Illustration of Aortic Prosthesis Peravalvular Leak

Case #1 Status post placement of prosthetic

peravalvular leak noted immediately post bypass.

Surgeon notified, location defined. Surgeon able to place annular stitches

off bypass. Leak no longer present. (not shown)

NA 1bb

Illustration of Aortic Prosthesis Peravalvular Leak

Case #2 58 yr old man presenting with bicuspid

aortic valve with stenosis. Prebypass echo notes severe leaflet

and annular calcification.

2

3

Post Bypass Case #2

Note peravalvular leak, adjacent to left main coronary artery.

Peravalvular leak not addressed.

46

53

Case #2

Patient returns 3 months later with symptoms.

On echo has peravavluar leak and prolapse prosthetic valve leaflet.

7

17

10

12

Case #2

Patient under went successful aortic valve replacement without complications.

 References:

1.  DeCicco, Beghi et al: Aortic Valve Periprosthetic Leakage: Anatomic Observations and Surgical Results. Ann Thorac Surg 2005;79:1480-5.

2. Rallidis et al: Natural History of Early Aortic Paraprostheitc Regurgitation: A Five Year Follow-up. Am Heart J 1999 Aug;138(2Pt 1):351-7.

3. O’Rourke et al: Outcome of Mild Periprosthetic Regurgitation Detected by Intraoperative Transesophageal Echocardiography. J Am Coll Card 2001;38:163-6.