Management and prognosis of surgical aortic and mitral prosthetic valve regurgitation
- Alvaro Marco del Castillo, MD
Alvaro Marco del Castillo, MD
- Professor of Medicine
- University Hospital Ramon and Cajal
- Pepe Zamorano, MD
Pepe Zamorano, MD
- Head of Cardiology
- University Hospital Ramon y Cajal
- Section Editors
- Patrizio Lancellotti, MD, PhD, FESC, FACC
Patrizio Lancellotti, MD, PhD, FESC, FACC
- Professor of Cardiology
- University of Liège Hospital
- Stephen JD Brecker, MD, FRCP, FESC, FACC
Stephen JD Brecker, MD, FRCP, FESC, FACC
- Section Editor — Valvular and Aortic Disease
- Chief of Cardiology
- Clinical Academic Group
- St. George's Hospital & University of London
Prosthetic valve dysfunction encompasses prosthetic valve obstruction (stenosis) and prosthetic valve regurgitation. Regurgitation associated with prosthetic heart valves includes regurgitation through the valve (transvalvular) as well as paravalvular regurgitation (also known as paravalvular leak[PVL]). Symptomatic severe prosthetic valve regurgitation is an uncommon complication of surgical valve replacement. However, it is associated with poor outcomes with both conservative management and surgical treatment.
This topic will discuss the prognosis and management of prosthetic valve regurgitation. Clinical manifestations and diagnosis of surgical prosthetic valve regurgitation as well as diagnosis and management of transcatheter heart valve regurgitation are discussed separately. (See "Clinical manifestations and diagnosis of surgical aortic and mitral prosthetic valve regurgitation" and "Transcatheter aortic valve implantation: Complications".)
Approach to management — The approach to management of prosthetic valve regurgitation includes monitoring asymptomatic patients, medical therapy for the cause of regurgitation (when treatable) and medical management of the sequelae of regurgitation, and evaluation of patients with severe prosthetic regurgitation for valve intervention (surgical or transcatheter), starting with determination of surgical risk.
Diagnosis and evaluation of prosthetic valve regurgitation is discussed separately. (See "Clinical manifestations and diagnosis of surgical aortic and mitral prosthetic valve regurgitation".)
●Asymptomatic patients with prosthetic valve regurgitation should be monitored, with frequency of monitoring based upon the severity of regurgitation and associated clinical findings. (See 'Monitoring' below.)
- Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2014; 129:2440.
- Taylor J. ESC/EACTS Guidelines on the management of valvular heart disease. Eur Heart J 2012; 33:2371.
- Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014; 63:e57.
- Joint Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology (ESC), European Association for Cardio-Thoracic Surgery (EACTS), Vahanian A, et al. Guidelines on the management of valvular heart disease (version 2012). Eur Heart J 2012; 33:2451.
- Nishimura RA, Otto CM, Bonow RO, et al. 2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2017.
- Dujardin KS, Enriquez-Sarano M, Schaff HV, et al. Mortality and morbidity of aortic regurgitation in clinical practice. A long-term follow-up study. Circulation 1999; 99:1851.
- Genoni M, Franzen D, Vogt P, et al. Paravalvular leakage after mitral valve replacement: improved long-term survival with aggressive surgery? Eur J Cardiothorac Surg 2000; 17:14.
- Taramasso M, Maisano F, Denti P, et al. Surgical treatment of paravalvular leak: Long-term results in a single-center experience (up to 14 years). J Thorac Cardiovasc Surg 2015; 149:1270.
- Bouhout I, Mazine A, Ghoneim A, et al. Long-term results after surgical treatment of paravalvular leak in the aortic and mitral position. J Thorac Cardiovasc Surg 2016; 151:1260.
- Kaneko T, Vassileva CM, Englum B, et al. Contemporary Outcomes of Repeat Aortic Valve Replacement: A Benchmark for Transcatheter Valve-in-Valve Procedures. Ann Thorac Surg 2015; 100:1298.
- Leontyev S, Borger MA, Davierwala P, et al. Redo aortic valve surgery: early and late outcomes. Ann Thorac Surg 2011; 91:1120.
- Jaussaud N, Gariboldi V, Grisoli D, et al. Risk of reoperation for mitral bioprosthesis dysfunction. J Heart Valve Dis 2012; 21:56.
- Maciejewski M, Piestrzeniewicz K, Bielecka-Dąbrowa A, et al. Redo surgery risk in patients with cardiac prosthetic valve dysfunction. Arch Med Sci 2011; 7:271.
- Sampaio RO, Silva FC Jr, Oliveira IS, et al. Postoperative outcome of patients with prosthetic valve leak. Arq Bras Cardiol 2009; 93:283.
- Ha JW, Chang BC, Chung N, Cho SH. Images in cardiology. Acute severe mitral regurgitation due to unusual detachment of bioprosthetic valve leaflet. Clin Cardiol 2000; 23:213.
- Fudim M, Markley RR, Robbins MA. Transcatheter aortic valve replacement for aortic bioprosthetic valve failure with cardiogenic shock. J Invasive Cardiol 2013; 25:625.
- Thomas M, Schymik G, Walther T, et al. Thirty-day results of the SAPIEN aortic Bioprosthesis European Outcome (SOURCE) Registry: A European registry of transcatheter aortic valve implantation using the Edwards SAPIEN valve. Circulation 2010; 122:62.
- Piazza N, Grube E, Gerckens U, et al. Procedural and 30-day outcomes following transcatheter aortic valve implantation using the third generation (18 Fr) corevalve revalving system: results from the multicentre, expanded evaluation registry 1-year following CE mark approval. EuroIntervention 2008; 4:242.
- Dvir D, Webb JG, Bleiziffer S, et al. Transcatheter aortic valve implantation in failed bioprosthetic surgical valves. JAMA 2014; 312:162.
- Webb JG, Mack MJ, White JM, et al. Transcatheter Aortic Valve Implantation Within Degenerated Aortic Surgical Bioprostheses: PARTNER 2 Valve-in-Valve Registry. J Am Coll Cardiol 2017; 69:2253.
- Alnasser S, Cheema AN, Simonato M, et al. Matched Comparison of Self-Expanding Transcatheter Heart Valves for the Treatment of Failed Aortic Surgical Bioprosthesis: Insights From the Valve-in-Valve International Data Registry (VIVID). Circ Cardiovasc Interv 2017; 10.
- Ejiofor JI, Yammine M, Harloff MT, et al. Reoperative Surgical Aortic Valve Replacement Versus Transcatheter Valve-in-Valve Replacement for Degenerated Bioprosthetic Aortic Valves. Ann Thorac Surg 2016; 102:1452.
- Murzi M, Berti S, Gasbarri T, et al. Transapical transcatheter mitral valve-in-valve implantation versus minimally invasive surgery for failed mitral bioprostheses†. Interact Cardiovasc Thorac Surg 2017.
- Ruiz CE, Jelnin V, Kronzon I, et al. Clinical outcomes in patients undergoing percutaneous closure of periprosthetic paravalvular leaks. J Am Coll Cardiol 2011; 58:2210.
- Millán X, Skaf S, Joseph L, et al. Transcatheter reduction of paravalvular leaks: a systematic review and meta-analysis. Can J Cardiol 2015; 31:260.
- Sorajja P, Cabalka AK, Hagler DJ, Rihal CS. Percutaneous repair of paravalvular prosthetic regurgitation: acute and 30-day outcomes in 115 patients. Circ Cardiovasc Interv 2011; 4:314.
- Noble S, Jolicoeur EM, Basmadjian A, et al. Percutaneous paravalvular leak reduction: procedural and long-term clinical outcomes. Can J Cardiol 2013; 29:1422.
- Taramasso M, Maisano F, Latib A, et al. Conventional surgery and transcatheter closure via surgical transapical approach for paravalvular leak repair in high-risk patients: results from a single-centre experience. Eur Heart J Cardiovasc Imaging 2014; 15:1161.
- Choudhary SK, Talwar S, Airan B. Choice of prosthetic heart valve in a developing country. Heart Asia 2016; 8:65.
- Nollert G, Miksch J, Kreuzer E, Reichart B. Risk factors for atherosclerosis and the degeneration of pericardial valves after aortic valve replacement. J Thorac Cardiovasc Surg 2003; 126:965.
- Hammermeister K, Sethi GK, Henderson WG, et al. Outcomes 15 years after valve replacement with a mechanical versus a bioprosthetic valve: final report of the Veterans Affairs randomized trial. J Am Coll Cardiol 2000; 36:1152.
- O'Rourke DJ, Palac RT, Malenka DJ, et al. Outcome of mild periprosthetic regurgitation detected by intraoperative transesophageal echocardiography. J Am Coll Cardiol 2001; 38:163.
- Cho IJ, Moon J, Shim CY, et al. Different clinical outcome of paravalvular leakage after aortic or mitral valve replacement. Am J Cardiol 2011; 107:280.
- Cho IJ, Hong GR, Lee S, et al. Predictors of prognosis in patients with mild to moderate paravalvular leakage after mitral valve replacement. J Card Surg 2014; 29:149.
- Approach to management
- Medical therapy
- - Treatment of cause of regurgitation
- - Treatment of consequences of regurgitation
- - Indications
- - Evidence
- On surgical treatment
- - For symptomatic patients
- - For asymptomatic patients
- On transcatheter valve-in-valve implantation
- - Aortic valve-in-valve procedure
- - Mitral valve-in-valve procedure
- On transcatheter closure of paravalvular leaks
- Transvalvular prosthetic regurgitation
- Paravalvular prosthetic regurgitation
- SUMMARY AND RECOMMENDATIONS