Surgical Transapical Approach for Prosthetic Mitral Paravalvular Leak Closure: Early Results

The objective is to demonstrate safety and early clinical results of surgical transapical closure of paravalvular leaks (PVLs) following mitral valve replacement in significant regurgitation. Between March 2014 and February 2015, 12 patients (mean age 52.1 +/- 6.0 years, 66.6% male) with severe symptomatic mitral PVLs (n=13) underwent surgical transapical closure procedure through left mini-thoracotomy. All patients were in NYHA functional class III-IV and median logistic EuroSCORE was 24.2 +/- 6.4% (range, 13.5-34.6%). Indications were heart failure (n=10) and symptomatic hemolysis (n=2) due to severe mitral regurgitation (MR). Amplatzer Vascular Plug-III devices (n=9) were used for smaller and regular defects; whereas Atrial Septal Defect closure devices (n=4) were used for larger defects. Technical success was achieved in 10 (83.3%) patients. One (8.5%) patient with 2+MR was treated medically. A patient with residual 4+MR underwent re-operation. There was no procedure-related complication including mortality, device migration, embolization, or cardiac laceration. Mean procedure and fluoroscopy times were 166.4 +/- 39.5 (range, 90-210) and 25.7 +/- 17.3 (range, 16-64) minutes, respectively. The mean intensive care and hospital stays were 2.1 +/- 1.3 and 10.3 +/- 6.5 days, respectively. Clinical efficacy was achieved in 9 (75%) of 12 patients at early follow-up of 8.5 +/- 2.1 months. NYHA status was class II in two patients, and no hemolytic anemia was diagnosed. Echocardiographic studies revealed a significant reduction of preoperative MR (3-4+) to less than 1+ MR after operations (P<0.05). Surgical transapical approach to PVL closure is a safe and effective procedure following mitral valve replacement. Early results show that this procedure can be an alternative to re-operation for high-risk patients. Further studies are needed to prove its effectiveness in the long term.