Periprosthetic Valve Regurgitation
Abstract & Commentary
Synopsis: Trivial to mild PPR on intraoperative echocardiograms was not uncommon, often disappeared by 6 weeks after surgery, and, if persistent, was almost always benign.
Source: O’Rourke DJ, et al. J Am Coll Cardiol. 2001;38:163-166.
Periprosthetic valve regurgitation is not infrequently observed following left heart valve replacement, but its clinical significance and prognosis are unclear. Thus, O’Rourke and colleagues evaluated intraoperative and follow-up echocardiograms in 608 patients undergoing left heart valve replacement at their institution. Periprosthetic regurgitation (PPR) was observed on intraoperative postcardiopulmonary bypass transesophageal echocardiography in 113 (18%) of these patients. PPR was trivial or mild in all cases since moderate or severe PPR was corrected before the patient left the operating room. A 6-week postoperative transthoracic echocardiogram showed no PPR in 56 patients and persistent, but unchanged, PPR in 44 of the 100 patients remaining. At late (2 years on average) follow-up 92 patients remained and echoes were performed on 50 patients. Four of these 50 showed progression of PPR (8%) and all 4 had bioprosthetic valves. Three of the 4 had no PPR on early follow-up. Of these 3, 2 had endocarditis and 1 had primary valvular degeneration. Thus, only 1 of the 50 patients remaining at late follow-up had progression of PPR (2%) and eventually at 3 years had their bioprosthetic valve replaced. Only small patient body size and use of a bioprosthetic valve were significant correlates with PPR by multivariate analysis. O’Rourke et al concluded that trivial to mild PPR on intraoperative echocardiograms was not uncommon, often disappeared by 6 weeks after surgery and, if persistent, was almost always benign.
Comment by Michael H. Crawford, MD
Trivial to mild PPR is usually ignored at surgery due to the belief that it is not important hemodynamically and may disappear as the spaces between sutures are obliterated by clotted blood or tissue ingrowth in the near future. The 6-month echo data in this study confirm that belief as the majority of the PPRs disappeared. Even when it persisted, it had no affect on 6-week morbidity or mortality and only 1 patient with PPR eventually underwent valve re-replacement due to progressive PPR.
The natural history of moderate or severe PPR cannot be deduced from this study since these patients routinely were put back on pump and repaired. It is possible that some moderate PPR may disappear or be well tolerated for years, I have certainly seen this, but predicting which patients will do well is uncertain, so O’Rourke et al’s surgical policy is not unreasonable. Presumably PPR is not highly likely to lead to infectious endocarditis, since the 2 endocarditis cases in this series did not have intraoperative PPR. However, the number of patients is relatively small for this determination.
Since the overall prognosis with PPR is excellent, the fact that all the cases in this study were observed with bioprosthetic valves is of little clinical importance. However, it is in keeping with the recent release of the 15 year VA valve surgery trial results showing the overall superiority of mechanical vs. bioprosthetic valves.