Does the morphology of mitral paravalvular leaks influence symptoms and hemolysis?

Background and aim of the study: Prosthetic mitral valve replacement (MVR) is associated with paravalvular leak in up to 12.5% of patients. The influe nce of the morphology and location of paravalvular leaks on clinical sympto ms and degree of leak-related hemolysis is unknown. Methods: Morphology, size, location and number of paravalvular leaks were a nalyzed in 96 consecutive patients with primary mitral paravalvular leaks. Results: Mitral leak was diagnosed a median of 119 days after primary MVR. A small (1-2 mm) paravalvular leak was found in 41 patients (43%), an inter mediate leak (3-5 mm) in 26 (27%), and a large leak (6-15 mm) in 29 (30%). Single leaks were observed in 70 patients (73%), whilst 26 (27%) had multip le leaks. Paravalvular leaks occurred around the entire prosthetic circumfe rence, but were seen predominantly around the mitral commissural areas (76 %). The larger the size of the leak, the more symptomatic the patient (p = 0.006); 80% of patients with small leaks were in NYHA classes I and IL whil st 62% with intermediate/large leaks were in NYHA classes III and IV. The n umber of leaks was not correlated with severity of clinical symptoms. Multi ple leaks were more likely to cause significant hemolysis. Patients with pr eoperative chronic renal insufficiency, postoperative infection or large (> 5 cm) left atria were more likely to develop multiple leaks. The size and l ocation of the leaks was surgeon-dependent. Conclusion: Intraoperative transesophageal echocardiography is mandatory to detect possible small leaks and technical errors. Strict monitoring of all MVR patients is necessary for prolonged periods, as the appearance of para valvular leaks is not necessarily correlated with clinical symptoms. Small paravalvular leaks, in particular, may go unnoticed. As the location and si ze of the leaks were significantly surgeon-dependent, self-monitoring shoul d be mandatory for all surgeons.