Case Study
Bioprosthetic aortic valve replacement on a mechanical valve ring
Asian Cardiovascular & Thoracic Annals 2015, Vol. 23(9) 1060–1061 ß The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492314531139 aan.sagepub.com
Omer Ashraf and Sumit Yadav
Abstract Mechanical valve failure is a known but rare occurrence in cardiac surgery. A 71-year-old lady underwent surgery for failure of her mechanical aortic valve. It was replaced with another mechanical valve. However, during operative manipulation, both leaflets fractured, resulting in a prolonged operative time. Under these circumstances, a novel approach was adopted and a bioprosthetic valve was implanted on the mechanical valve sewing ring as a final resort. The intervention was successful. This illustrates a case of the need for innovative approaches in cardiac surgery.
Keywords Aortic valve, Heart valve prosthesis implantation, Prosthesis failure
Case Report A 71-year-old lady had undergone an aortic valve replacement with a 25-mm Carbomedics mechanical valve 16 years earlier for severe aortic stenosis. The postoperative course after her initial surgery was unremarkable, but she presented twice with angina and shortness of breath on exertion 5 and 11 years later. Her symptoms progressively worsened. Coronary angiography after 11 years revealed normal coronary anatomy with no significant disease. Echocardiography showed evidence of severe aortic stenosis with a mean gradient of 32 mm Hg across the mechanical valve and restricted prosthetic valve leaflet mobility, confirmed by fluoroscopy. She was therefore admitted for redo aortic valve replacement. Her comorbidities included hypertension, dyslipidemia, obesity, atrial fibrillation, Crohn’s disease, hypothyroidism, and osteoarthritis. Intraoperatively, there were dense pericardial adhesions which were dissected. Following aortotomy and inspection of the prosthetic valve, it was discovered that the base of anterior mitral valve leaflet (AMVL) was severely adherent to the valve ring. As a result, part of the AMVL was removed along with the valve. The AMVL was reconstructed with a pericardial patch, and the aortic root was reconstructed with a patch because removal of the prosthetic valve involved going all the way down to the aorto-mitral curtain. A 27-mm St. Jude Medical mechanical valve was sutured to the
annulus, but the reconstructed AMVL was found to be coming in the way of the prosthetic valve. The prosthetic valve was therefore rotated. Following rotation, one of the mechanical valve leaflets dislodged and fell into the left ventricle. It was retrieved. Unfortunately, as an attempt was made to remove the other mechanical valve leaflet, it too fractured and fell into the left ventricle in multiple pieces. Consequently, the left atrium was opened and a thoracoscope was used to meticulously remove all parts of the broken leaflet. At this stage, it was decided to adopt a novel approach owing to the mounting cardiopulmonary bypass and clamp times, and suture a tissue valve to the mechanical valve ring as a final resort. A size 27-mm Mitroflow tissue valve was sutured to the St. Jude Medical valve ring with 2/0 Ti-Cron sutures; the bioprosthetic valve was thus seated on the mechanical valve cage (Figure 1). The rest of the procedure was uneventful. Transesophageal echocardiography at the end of the procedure showed normal seating and gradients across aortic valve, and moderate regurgitation across
Department of Cardiothoracic Surgery, The Townsville Hospital, Douglas, Australia Corresponding author: Omer Ashraf, Department of Cardiothoracic Surgery, The Townsville Hospital, 100 Angus Smith Drive, Douglas, Qld 4814, Australia. Email: [email protected]
Downloaded from aan.sagepub.com at Kungl Tekniska Hogskolan / Royal Institute of Technology on November 14, 2015
Ashraf and Yadav
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Figure 1. Postoperative plain chest radiograph showing the bioprosthetic valve ring sewn on the mechanical valve cage.
attempting to replace it completely with another valve, a bioprosthetic valve was sutured onto the mechanical valve sewing ring. This was successful, and the patient survived the long procedure. Unfortunately, she developed moderate mitral regurgitation and cardiac dysrhythmia following postoperatively, and needed a permanent pacemaker. However, she tolerated both pathologies, and did well during her remaining inpatient course and the outpatient follow-up. To our knowledge, this is the first report of implantation of a bioprosthetic valve on a mechanical valve ring. This case illustrates the need for innovative approaches in cardiac surgery under difficult intraoperative settings. Even though fracture of a prosthetic cardiac valve is a known but rare entity,1–5 its occurrence intraoperatively and rectification by placement of a new valve superimposed on the preexisting valve cage has not been previously described. Funding
the mitral valve, which was acceptable. The patient was transferred to the intensive care unit and extubated the next day. Her postoperative course was marked by tachy-brady-arrhythmias with symptomatic pauses, for which she needed a permanent pacemaker. She made a gradual recovery and was discharged 11 days after her surgery. She has been followed up since then and has remained well from a cardiac perspective. A recent transthoracic echocardiogram revealed the prosthetic aortic valve to be well seated with a mean gradient of 12 mm Hg and peak gradient of 24 mm Hg.
Discussion This is an interesting case of a patient with complex valvular pathology in a redo setting, who although under experienced cardiac surgical hands, developed complications during the procedure. The complications were dealt with as they occurred, but as the cardiopulmonary bypass and clamp time increased, the need for an innovative approach to fix the problem became apparent. The problem was placing a prosthetic aortic valve in an annulus in a redo setting with a mechanical valve cage in situ with broken leaflets. Instead of
This research received no specific grant from any funding agency in the public, commerical, or not-for-profit sectors.
Conflicts of interest statement None declared.
References 1. Grande RD and Katz WE. Acute aortic regurgitation secondary to disk embolization of a Bjo¨rk-Shiley prosthetic aortic valve. J Am Soc Echocardiogr 2011; 24: 350. 2. Cianciulli TF, Lax JA, Saccheri MC, et al. Retrieval of a leaflet escaped in a Tri-technologies bileaflet mechanical prosthetic valve. Eur J Echocardiogr 2008; 9: 65–68. 3. Jazayeri S, Meunier JP, Tatou E, et al. Fracture embolization of a Tekna mitral prosthesis: case report. J Heart Valve Dis 2001; 10: 219–221. 4. Mert M, Ozkara A and Hatemi A. Leaflet escape in a revised Edwards-Duromedics mitral prosthesis. J Heart Valve Dis 2000; 12: 513–515. 5. Mosterd A, Shahin GM, van Boven WJ, Jaarsma W, Graafland AD and van Swieten HA. Images in cardiovascular medicine. Leaflet fracture of a St. Jude mechanical bileaflet valve. Circulation 2005; 111: e280–e281.
Downloaded from aan.sagepub.com at Kungl Tekniska Hogskolan / Royal Institute of Technology on November 14, 2015
Bioprosthetic aortic valve replacement on a mechanical valve ring
Asian Cardiovascular & Thoracic Annals 2015, Vol. 23(9) 1060–1061 ß The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492314531139 aan.sagepub.com
Omer Ashraf and Sumit Yadav
Abstract Mechanical valve failure is a known but rare occurrence in cardiac surgery. A 71-year-old lady underwent surgery for failure of her mechanical aortic valve. It was replaced with another mechanical valve. However, during operative manipulation, both leaflets fractured, resulting in a prolonged operative time. Under these circumstances, a novel approach was adopted and a bioprosthetic valve was implanted on the mechanical valve sewing ring as a final resort. The intervention was successful. This illustrates a case of the need for innovative approaches in cardiac surgery.
Keywords Aortic valve, Heart valve prosthesis implantation, Prosthesis failure
Case Report A 71-year-old lady had undergone an aortic valve replacement with a 25-mm Carbomedics mechanical valve 16 years earlier for severe aortic stenosis. The postoperative course after her initial surgery was unremarkable, but she presented twice with angina and shortness of breath on exertion 5 and 11 years later. Her symptoms progressively worsened. Coronary angiography after 11 years revealed normal coronary anatomy with no significant disease. Echocardiography showed evidence of severe aortic stenosis with a mean gradient of 32 mm Hg across the mechanical valve and restricted prosthetic valve leaflet mobility, confirmed by fluoroscopy. She was therefore admitted for redo aortic valve replacement. Her comorbidities included hypertension, dyslipidemia, obesity, atrial fibrillation, Crohn’s disease, hypothyroidism, and osteoarthritis. Intraoperatively, there were dense pericardial adhesions which were dissected. Following aortotomy and inspection of the prosthetic valve, it was discovered that the base of anterior mitral valve leaflet (AMVL) was severely adherent to the valve ring. As a result, part of the AMVL was removed along with the valve. The AMVL was reconstructed with a pericardial patch, and the aortic root was reconstructed with a patch because removal of the prosthetic valve involved going all the way down to the aorto-mitral curtain. A 27-mm St. Jude Medical mechanical valve was sutured to the
annulus, but the reconstructed AMVL was found to be coming in the way of the prosthetic valve. The prosthetic valve was therefore rotated. Following rotation, one of the mechanical valve leaflets dislodged and fell into the left ventricle. It was retrieved. Unfortunately, as an attempt was made to remove the other mechanical valve leaflet, it too fractured and fell into the left ventricle in multiple pieces. Consequently, the left atrium was opened and a thoracoscope was used to meticulously remove all parts of the broken leaflet. At this stage, it was decided to adopt a novel approach owing to the mounting cardiopulmonary bypass and clamp times, and suture a tissue valve to the mechanical valve ring as a final resort. A size 27-mm Mitroflow tissue valve was sutured to the St. Jude Medical valve ring with 2/0 Ti-Cron sutures; the bioprosthetic valve was thus seated on the mechanical valve cage (Figure 1). The rest of the procedure was uneventful. Transesophageal echocardiography at the end of the procedure showed normal seating and gradients across aortic valve, and moderate regurgitation across
Department of Cardiothoracic Surgery, The Townsville Hospital, Douglas, Australia Corresponding author: Omer Ashraf, Department of Cardiothoracic Surgery, The Townsville Hospital, 100 Angus Smith Drive, Douglas, Qld 4814, Australia. Email: [email protected]
Downloaded from aan.sagepub.com at Kungl Tekniska Hogskolan / Royal Institute of Technology on November 14, 2015
Ashraf and Yadav
1061
Figure 1. Postoperative plain chest radiograph showing the bioprosthetic valve ring sewn on the mechanical valve cage.
attempting to replace it completely with another valve, a bioprosthetic valve was sutured onto the mechanical valve sewing ring. This was successful, and the patient survived the long procedure. Unfortunately, she developed moderate mitral regurgitation and cardiac dysrhythmia following postoperatively, and needed a permanent pacemaker. However, she tolerated both pathologies, and did well during her remaining inpatient course and the outpatient follow-up. To our knowledge, this is the first report of implantation of a bioprosthetic valve on a mechanical valve ring. This case illustrates the need for innovative approaches in cardiac surgery under difficult intraoperative settings. Even though fracture of a prosthetic cardiac valve is a known but rare entity,1–5 its occurrence intraoperatively and rectification by placement of a new valve superimposed on the preexisting valve cage has not been previously described. Funding
the mitral valve, which was acceptable. The patient was transferred to the intensive care unit and extubated the next day. Her postoperative course was marked by tachy-brady-arrhythmias with symptomatic pauses, for which she needed a permanent pacemaker. She made a gradual recovery and was discharged 11 days after her surgery. She has been followed up since then and has remained well from a cardiac perspective. A recent transthoracic echocardiogram revealed the prosthetic aortic valve to be well seated with a mean gradient of 12 mm Hg and peak gradient of 24 mm Hg.
Discussion This is an interesting case of a patient with complex valvular pathology in a redo setting, who although under experienced cardiac surgical hands, developed complications during the procedure. The complications were dealt with as they occurred, but as the cardiopulmonary bypass and clamp time increased, the need for an innovative approach to fix the problem became apparent. The problem was placing a prosthetic aortic valve in an annulus in a redo setting with a mechanical valve cage in situ with broken leaflets. Instead of
This research received no specific grant from any funding agency in the public, commerical, or not-for-profit sectors.
Conflicts of interest statement None declared.
References 1. Grande RD and Katz WE. Acute aortic regurgitation secondary to disk embolization of a Bjo¨rk-Shiley prosthetic aortic valve. J Am Soc Echocardiogr 2011; 24: 350. 2. Cianciulli TF, Lax JA, Saccheri MC, et al. Retrieval of a leaflet escaped in a Tri-technologies bileaflet mechanical prosthetic valve. Eur J Echocardiogr 2008; 9: 65–68. 3. Jazayeri S, Meunier JP, Tatou E, et al. Fracture embolization of a Tekna mitral prosthesis: case report. J Heart Valve Dis 2001; 10: 219–221. 4. Mert M, Ozkara A and Hatemi A. Leaflet escape in a revised Edwards-Duromedics mitral prosthesis. J Heart Valve Dis 2000; 12: 513–515. 5. Mosterd A, Shahin GM, van Boven WJ, Jaarsma W, Graafland AD and van Swieten HA. Images in cardiovascular medicine. Leaflet fracture of a St. Jude mechanical bileaflet valve. Circulation 2005; 111: e280–e281.
Downloaded from aan.sagepub.com at Kungl Tekniska Hogskolan / Royal Institute of Technology on November 14, 2015
