Xavier Millán1, Ismail Bouhout2, Anna Nozza3, Karla Samman1, Louis-Mathieu Stevens2, Yoan Lamarche2, Antonio Serra4, Anita W Asgar1, Ismail El-Hamamsy2, Raymond Cartier2, Michel Pellerin2, Stephane Noble5, Phillipe Demers2, Reda Ibrahim1, E Marc Jolicœur6, Denis Bouchard2. 1. Department of Medicine, Montreal Heart Institute, Université de Montréal, Montreal, Canada. 2. Division of Cardiac Surgery, Université de Montréal, Montreal, Canada. 3. Department of Medicine, Montreal Heart Institute, Université de Montréal, Montreal, Canada; Montreal Health Innovations Coordinating Center, Montreal Heart Institute, Université de Montréal, Montreal, Canada. 4. Division of Interventional Cardiology, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain. 5. Department of Medical Specialties, Cardiology Division, Université de Genève, Geneva, Switzerland. 6. Department of Medicine, Montreal Heart Institute, Université de Montréal, Montreal, Canada. Electronic address: marc.jolicoeur@icm-mhi.org.
Abstract
OBJECTIVES: This study sought to assess the relative merit of surgical correction (SC) versus transcatheter reduction on long-term outcomes in patients with significant paravalvular leak (PVL) refractory to medical therapy. BACKGROUND: PVL is the most frequent dysfunction following prosthetic valve replacement. Although repeat surgery is the gold standard, transcatheter reduction (TR) of PVL has been associated with reduced mortality. METHODS: From 1994 to 2014, 231 patients underwent SC (n = 151) or TR (n = 80) PVL correction. Propensity matching and Cox proportional hazards regression models were used to assess the effect of either intervention on long-term rates of all-cause death or hospitalization for heart failure. Survival after TR and SC were further compared with the survival in a matched general population and to matched patients undergoing their first surgical valve replacement. RESULTS: Over a median follow-up of 3.5 years, SC was associated with an important reduction in all-cause death or hospitalization for heart failure compared with TR (hazard ratio: 0.28; 95% confidence interval: 0.18 to 0.44; p < 0.001). There was a trend towards reduced all-cause death following SC versus TR (hazard ratio: 0.61; 95% confidence interval: 0.37 to 1.02; p = 0.06). Neither intervention normalized survival when compared with a general population or patients undergoing their first surgical valve replacement. CONCLUSIONS: In patients with significant prosthetic PVL, surgery is associated with better long-term outcomes compared with transcatheter intervention, but results in important perioperative mortality and morbidity. Future studies are needed in the face of increasing implementation of transcatheter PVL interventions across the world.
OBJECTIVES: This study sought to assess the relative merit of surgical correction (SC) versus transcatheter reduction on long-term outcomes in patients with significant paravalvular leak (PVL) refractory to medical therapy. BACKGROUND: PVL is the most frequent dysfunction following prosthetic valve replacement. Although repeat surgery is the gold standard, transcatheter reduction (TR) of PVL has been associated with reduced mortality. METHODS: From 1994 to 2014, 231 patients underwent SC (n = 151) or TR (n = 80) PVL correction. Propensity matching and Cox proportional hazards regression models were used to assess the effect of either intervention on long-term rates of all-cause death or hospitalization for heart failure. Survival after TR and SC were further compared with the survival in a matched general population and to matched patients undergoing their first surgical valve replacement. RESULTS: Over a median follow-up of 3.5 years, SC was associated with an important reduction in all-cause death or hospitalization for heart failure compared with TR (hazard ratio: 0.28; 95% confidence interval: 0.18 to 0.44; p < 0.001). There was a trend towards reduced all-cause death following SC versus TR (hazard ratio: 0.61; 95% confidence interval: 0.37 to 1.02; p = 0.06). Neither intervention normalized survival when compared with a general population or patients undergoing their first surgical valve replacement. CONCLUSIONS: In patients with significant prosthetic PVL, surgery is associated with better long-term outcomes compared with transcatheter intervention, but results in important perioperative mortality and morbidity. Future studies are needed in the face of increasing implementation of transcatheter PVL interventions across the world.
Authors: Joseph M Venturini; Isla McClelland; John E A Blair; Akhil Narang; Rohan Kalathiya; Roberto M Lang; Karima Addetia; Jonathan Paul; Sandeep Nathan; Atman P Shah Journal: J Invasive Cardiol Date: 2019-06-15 Impact factor: 2.022