| BackgroudValvular heart disease is caused by rheumatic,bacterial infection and other reasons.After decades,artificial heart valve replacement has become a mature method for the treatment of valvular diseases.Recently,with the continuous reform and application of valve replacement,interventional minimally invasive surgery has gradually become a new method for the treatment of valvular disease.Paravalvular leakage(PVL)is a specific complication after valve replacement.However,the incidence was not reported statistically in China.Postoperative complications such as loosening and breaking of the annulus suture can lead to PVL around the artificial annulus.In foreign literatures,the incidence of PVL after surgical valve replacement is about 2 to 10%,and it is about 7 to 17% in the mitral valve replacement.The incidence of mitral valve circumferential PVL is significantly higher than that of aortic valve replacement.Mechanical or biological valve replacement can be associated with PVL.In recent years,with the extensive application of TAVR and TMVR,the incidence of PVL after operation is significantly higher than that of traditional surgery,which is about 12-30%.As different degrees of PVL,the clinical manifestation varies.It is easy to occur in the early stage after valve replacement.The early data shows that the incidence of mitral valve replacement was 9%,and aortic valve replacement was 13%.Although the operation technology has been improved,the incidence of PVL has not yet been decreased due to various complex reasons.Traditional idea is that larger PVL can cause complications such as heart failure,arrhythmia,hemolysis,endocarditis and other complications.However,a small PVL often causes complications such as hemolysis and endocarditis.The above situation often requires valve replacement again,while the recurrence of the chest increases the risk of the operation which is associated with an increase in the mortality rate after the operation.In this paper,we investigated the safety and efficacy of interventional occlusion in the treatment of periprosthetic leakage after replacement through clinical practice.Then we compared it with traditional surgical methods to accumulate more clinical experience for interventional therapy.Objective1.To evaluate the safety and efficacy of transcatheter intervention of PVL after mitral valve replacement.2.To compare the safety and efficacy between transcatheter intervention and surgical closure of PVL after valve replacement.Methods1.From April 2014 to May 2017,42 patients of PVL after mitral valve replacement underwent interventional therapy.There were 24 male and 18 female with mean age= 51.5±11.6 years.Previously,15 patients underwent mitral valve replacement only,13 patients underwent aortic valve replacement only,9 patients had aortic valve replacement and mitral valve replacement,2 patients underwent TVR,3 patients underwent mitral valve replacement and coronary artery bypass grafting.10 patients had a history of previous infective endocarditis.25 patients used mechanical valve and the other 17 patients used biological valve.There were 22 cases of NYHA heart function= III,20 cases= IV.The period of time between transcatheter intervention and previous operation was 4.8±3.7 years,with mitral regurgitation volume=12.8±3.2 ml.Transcatheter intervention was carried out in the catheterization laboratory or the hybrid operation room with the patient under local anesthesia first.By puncturing femoral artery and implantation of different congenital heart disease devices,the mitral PVL were occluded interventionally.To some complicated cases which need two valves replacement,the occluder can be implanted by puncturing apex and atrial septum.Follow-up evaluation included peri-operational mortality,complications and postoperative residual shunt.The average follow-up time was 12 months.2.From May 2010 to April 2014,17 patients of PVL after valve replacement underwent interventional therapy and 11 patients underwent surgical closure.The perioperative characters,mortality rate,complications and prognosis were compared between the patients underwent surgical procedure and transcatheter intervention.The average follow-up time was 12 months.Results1.The success rate of transcatheter intervention was 95.2%.Apart from 2 patients who was implanted with no occluder,2 patients were implanted with 2 occluders with the other 12 patients had one occluder each.In total,there were 4 muscular ventricular septal defect occluders,2 patent ductus arteriosus occluders and 10 vascular plugs.The average operation time was 121.5±49.7 min,and the DSA radiation time was 20.0 ± 9.0 min,with average hospitalization time of 11.2±10.0 d.The main post-operative complications included 1 case of hemoptysis(2.3%),2 cases of acute renal failure(4.7%),1 case of hematuria(2.3%)and 4 cases of blood transfusion(11.9%).During the follow-up,there was no death.The regurgitation volume decreased to 0.54±0.74 ml(p<0.05).2 patients was implanted with no occluders for the sake of intolerance of the intervention,and the remaining 40 patients live well,with improved heart function and no serious complications.2.The success rate of transcatheter intervention was 100%,while there were 2 in-hospital deaths in the surgical group(18%).Compared with surgical group,transcatheter intervention group has the benefit of shorter operation time(84±36min VS 358±88minm P<0.01),shorter hospitalization time(11.9±12.1d VS 38.1±42.2d,P<0.05).There was no mechanical ventilation and ICU stay in the transcatheter intervention group.After transcatheter intervention,there was 7 residual shunt(47%)with an average shunt volume of 1.6±1.7mL,which is remarkably reduced compared with pre-operation.In the surgical group,there was 1 case of residual shunt(9%).During the follow-up,there was no deaths in both groups,with improved heart function and no serious complications.Conclusion1.The traditional treatment of PVL after mitral valve replacement need thoracotomy,extracorporeal circulation and open surgery.There was great trauma,high risk and many complications.Transcatheter intervention of mitral PVL has the advantages of being a simpler and safer approach,less trauma,shorter time of hospitalization and faster post-operative recovery.This method is one of the new technologies in the field of minimally invasive cardiac surgery in recent years.By improving operation skills,choosing individualized occluders and treatment of early hemolytic complications,the success rate and long-term effect of interventional therapy can get further improved.2.In the treatment of PVL after valve replacement,transcatheter intervention technique has the advantages of simpler and safe approach,less trauma,shorter time of hospitalization and faster post-operative recovery.This method is one of the new technology in the field of minimally invasive cardiac surgery in recent years.By improving operation skills,choosing individualized occluders and treatment of early hemolytic complications,the success rate and long-term effect of interventional therapy can get further improved.3.This study confirms the safety and effectiveness of interventional therapy for PVL,which reflects the advantages compared with traditional surgery.It consolidates the clinical experience of interventional therapy for PVL,which has laid a solid foundation for interventional treatment of PVL. |
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