Author + information
- Received March 22, 2017
- Revision received July 26, 2017
- Accepted August 3, 2017
- Published online October 2, 2017.
- Xavier Millán, MDa,
- Ismail Bouhout, MD, MScb,
- Anna Nozza, MSca,c,
- Karla Sammana,
- Louis-Mathieu Stevens, MD, PhDb,
- Yoan Lamarche, MD, MScb,
- Antonio Serra, MD, PhDd,
- Anita W. Asgar, MDa,
- Ismail El-Hamamsy, MD, PhDb,
- Raymond Cartier, MDb,
- Michel Pellerin, MDb,
- Stephane Noble, MDe,
- Phillipe Demers, MD, MScb,
- Reda Ibrahim, MDa,
- E. Marc Jolicœur, MD, MSc, MHSa,∗ ( and )
- Denis Bouchard, MD, PhDb
- aDepartment of Medicine, Montreal Heart Institute, Université de Montréal, Montreal, Canada
- bDivision of Cardiac Surgery, Université de Montréal, Montreal, Canada
- cMontreal Health Innovations Coordinating Center, Montreal Heart Institute, Université de Montréal, Montreal, Canada
- dDivision of Interventional Cardiology, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
- eDepartment of Medical Specialties, Cardiology Division, Université de Genève, Geneva, Switzerland
- ↵∗Address for correspondence:
Dr. E. Marc Jolicœur, Montreal Heart Institute, 5000 Bélanger Est, Montréal, Québec H1T 1C8, Canada.
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.
- cardiac surgery
- heart valve replacement
- interventional cardiology
- paravalvular leak
- prosthetic heart valves
Dr. Millán was supported by a research grant from Nova Domus (Erasmus Mundus program of the European Union). Dr. Jolicœur was supported by research grants from les Fonds la Recherche du Québec en santé, the Canadian Institutes for Health Research, the Canada Foundation for Innovation, the AGE-WELL Networks of Centres of Excellence, and la Fondation de l’Institut de Cardiologie de Montréal. Dr. Demers has received proctorship fees from Sorin Canada (modest). Dr. Ibrahim has served as a consultant for St. Jude Medical (modest); and as a proctor and consultant for Abbott, Boston Scientific, and Gore. Dr. Bouchard has received proctorship and lecture fees from Sorin and Edwards Canada (modest). All other authors have reported that they have no relationships relevant to the contents of this paper to disclose. Drs. Millán and Bouhout contributed equally to this work and are joint first authors. Drs. Jolicœur and Bouchard contributed equally to this work and are co-senior authors.
- Received March 22, 2017.
- Revision received July 26, 2017.
- Accepted August 3, 2017.
- 2017 American College of Cardiology Foundation