Case Study
Redo mitral valve replacement using the valve-on-valve method
Asian Cardiovascular & Thoracic Annals 2015, Vol. 23(6) 707–709 ß The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492314524206 aan.sagepub.com
Satoshi Miyairi, Masaaki Koide, Yoshifumi Kunii, Kazumasa Tsuda, Yuko Ohashi and Takashi Harada
Abstract Despite improvements in bioprosthetic valve function, increased human life-expectancy has led to a growing number of bioprosthetic valve deterioration cases requiring reoperation. We report 2 cases of primary tissue failure of a bioprosthetic valve, which were treated by mitral valve replacement using the valve-on-valve method. The reasons for the reoperations were a severely calcified valve annulus, and severe adhesion of a previous bioprosthetic valve. We removed only the leaflets of the bioprosthetic valve and sutured a Carbomedics OptiForm valve onto the sewing cuff of the previous bioprosthesis. No complications, including major cardiac events, were noted during the follow-up.
Keywords Heart valve prosthesis implantation, mitral valve, prosthesis failure, reoperation, suture techniques
Introduction Bioprosthetic valves have improved in terms of durability, function, and outcome. However, increased human life-expectancy has led to an increased number of valve deterioration cases. We report 2 cases of redo mitral valve replacement (MVR) using the valve-on-valve method, which is appropriate for redo MVR in patients with severe annulus calcification or adhesion.
Case reports Case 1 A 78-year-old man presented with a history of aortic valve replacement with a 19-mm Carpentier-Edwards Perimount valve (Edwards Lifesciences, Irvine, CA, USA) and MVR with a 25-mm Carpentier-Edwards Perimount valve at 74 years of age. He was undergoing hemodialysis for chronic kidney disease and had a pacemaker implanted for atrioventricular block. He had been followed up for progressive chronic heart failure due to primary tissue failure of the mitral bioprosthesis. Transthoracic echocardiography showed mitral valve stenosis (MS) and regurgitation (MR). Computed tomography revealed notable mitral valve and annulus calcification. Surgery was scheduled due
to his heart failure. We performed redo MVR using a 23-mm Carbomedics OptiForm valve (Sulzer Medica, Austin, TX, USA). After a repeat median sternotomy and synechiotomy, cardiopulmonary bypass was initiated via the ascending aorta and bicaval cannulation. The mitral prosthesis was examined through a right-sided left atriotomy. The mitral annulus was covered with intima, and the bioprosthesis leaflet was rigidly stiffened due to primary tissue failure. Removing the bioprosthesis would have been difficult due to severe mitral annulus and atrial wall calcification. Therefore, only the leaflets were resected while the sewing cuff was retained on the annulus. A 23-mm Carbomedics OptiForm valve was implanted onto the sewing cuff. The patient’s postoperative course was good with no MS or MR. He was discharged on the 15th postoperative day.
Department of Cardiovascular Surgery, Seirei Hamamatsu General Hospital, Hamamatsu, Japan Corresponding author: Satoshi Miyairi, MD, Department of Cardiovascular Surgery, Seirei Hamamatsu General Hospital, 2-12-12, Sumiyoshi, Naka-ku, Hamamatsu-City, Shizuoka 430-8558, Japan. Email: [email protected]
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Asian Cardiovascular & Thoracic Annals 23(6)
Case 2 A 66-year-old woman, who had undergone mitral commissurotomy for MS and MVR with a 29-mm IonescuShiley valve (Shiley, Inc., Irvine, CA, USA) at 30 and 36 years of age, presented to our hospital. Laboratory data indicated progressive hemolysis and anemia. Transthoracic echocardiography revealed severe MS, trivial MR, and an enlarged left atrium. We diagnosed the patient with heart failure and primary tissue failure of the mitral bioprosthesis, and scheduled surgery. We performed redo MVR using a 25-mm Carbomedics OptiForm valve. After a repeat median sternotomy, synechiotomy, and cardiopulmonary bypass establishment, the mitral bioprosthesis was examined through a right-sided left atriotomy. The annulus was largely covered with intima, and the bioprosthesis leaflets had become rigid and fragile. Because the artificial valve was firmly attached to the mitral annulus and its stent post had become embedded in the left ventricular posterior wall, only the leaflets were removed. A 25-mm Carbomedics OptiForm valve was sutured onto the sewing cuff. The postoperative course was uneventful with no MS or MR, and the patient was discharged on the 14th postoperative day.
Discussion Bioprosthetic degeneration including primary tissue failure is the most common reason for reoperation.1 The risk associated with mitral valve redo operations is high. Firm adhesion to the mitral annulus or embedding of the stent post in the left ventricular wall makes valve removal difficult. Removal of such adhesion or calcification may cause postoperative left ventricular rupture or paravalvular leak. Geha and colleagues1 reported good outcomes from 34 valve-on-valve cases. Stassano and colleagues2 also reported successful midterm outcomes with the valveon-valve technique. Shibata and colleagues3 described the suitability of valves for this method. We also previously reported a case of valve-on-valve replacement.4 We opted for the valve-on-valve method with the Carbomedics OptiForm mechanical valve. The OptiForm valve is the most suitable valve for valveon-valve replacement, in terms of profile and size.3 Moreover, the OptiForm valve is superior in terms of fitting to the sewing cuff of the previous bioprosthesis. Because the OptiForm sewing cuff is soft and has a center top shape, it can be fitted firmly to the old sewing cuff. We devised a method to suture the new valve to the old bioprosthesis, wherein pledgeted mattress sutures are applied to the previous sewing cuff, and the needles are passed through the OptiForm sewing cuff from the bottom, emerging at the side of
the top of the OptiForm cuff (Figure 1). Thus the OptiForm sewing cuff fits firmly onto the old sewing ring (Figure 2). In case 1, because a 25-mm mechanical mitral prosthesis had been used previously, the body
Figure 1. Pledgeted mattress sutures were applied to the sewing cuff of the previous bioprosthesis, and the needles were passed through the sewing cuff of the Carbomedics OptiForm valve, from the bottom to the side of the top of the cuff (arrow).
Figure 2. The sewing cuff of the Carbomedics OptiForm valve is soft, and the sutured cuff fits well on the previous sewing ring (arrow).
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surface area was 1.34 m2, and marked calcification was present around the mitral annulus including the left atrium, we opted for a 23-mm OptiForm valve for redo MVR via the valve-on-valve method. No poor seating or leak was observed, and an excellent hemodynamic outcome was obtained. We concluded that the valve-on-valve method is appropriate for avoiding left ventricular rupture or a major paravalvular leak in cases of redo mitral valve replacement. Moreover, good results were obtained. Funding This research received no specific grant from any funding agency in the public, commerical, or not-for-profit sectors.
References 1. Geha AS, Massad MG and Snow NJ. Replacement of degenerated mitral and aortic bioprostheses without explantation. Ann Thorac Surg 2001; 72: 1509–1514. 2. Stassano P, Musumeci A, Losi MA, Gagliardi C and Spampinato N. Mid-term results of the valve-on-valve technique for bioprosthetic failure. Eur J Cardiothorac Surg 2000; 18: 453–457. 3. Shibata T, Inoue K, Ikuta T, Bito Y, Yoshioka Y and Mizoguchi H. Which valve and which size should we use in the valve-on-valve technique for re-do mitral valve surgery? Interact Cardiovasc Thorac Surg 2009; 8: 206–210. 4. Tateishi M, Koide M, Kunii Y, Watanabe K and Ohsawa M. Valve-in-valve replacement of primary tissue valve failure of bovine pericardial valve minor. Kyobu Geka 2006; 59: 61–64.
Conflict of interest statement None declared.
Downloaded from aan.sagepub.com at UNIV NEBRASKA LIBRARIES on January 9, 2016
Redo mitral valve replacement using the valve-on-valve method
Asian Cardiovascular & Thoracic Annals 2015, Vol. 23(6) 707–709 ß The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492314524206 aan.sagepub.com
Satoshi Miyairi, Masaaki Koide, Yoshifumi Kunii, Kazumasa Tsuda, Yuko Ohashi and Takashi Harada
Abstract Despite improvements in bioprosthetic valve function, increased human life-expectancy has led to a growing number of bioprosthetic valve deterioration cases requiring reoperation. We report 2 cases of primary tissue failure of a bioprosthetic valve, which were treated by mitral valve replacement using the valve-on-valve method. The reasons for the reoperations were a severely calcified valve annulus, and severe adhesion of a previous bioprosthetic valve. We removed only the leaflets of the bioprosthetic valve and sutured a Carbomedics OptiForm valve onto the sewing cuff of the previous bioprosthesis. No complications, including major cardiac events, were noted during the follow-up.
Keywords Heart valve prosthesis implantation, mitral valve, prosthesis failure, reoperation, suture techniques
Introduction Bioprosthetic valves have improved in terms of durability, function, and outcome. However, increased human life-expectancy has led to an increased number of valve deterioration cases. We report 2 cases of redo mitral valve replacement (MVR) using the valve-on-valve method, which is appropriate for redo MVR in patients with severe annulus calcification or adhesion.
Case reports Case 1 A 78-year-old man presented with a history of aortic valve replacement with a 19-mm Carpentier-Edwards Perimount valve (Edwards Lifesciences, Irvine, CA, USA) and MVR with a 25-mm Carpentier-Edwards Perimount valve at 74 years of age. He was undergoing hemodialysis for chronic kidney disease and had a pacemaker implanted for atrioventricular block. He had been followed up for progressive chronic heart failure due to primary tissue failure of the mitral bioprosthesis. Transthoracic echocardiography showed mitral valve stenosis (MS) and regurgitation (MR). Computed tomography revealed notable mitral valve and annulus calcification. Surgery was scheduled due
to his heart failure. We performed redo MVR using a 23-mm Carbomedics OptiForm valve (Sulzer Medica, Austin, TX, USA). After a repeat median sternotomy and synechiotomy, cardiopulmonary bypass was initiated via the ascending aorta and bicaval cannulation. The mitral prosthesis was examined through a right-sided left atriotomy. The mitral annulus was covered with intima, and the bioprosthesis leaflet was rigidly stiffened due to primary tissue failure. Removing the bioprosthesis would have been difficult due to severe mitral annulus and atrial wall calcification. Therefore, only the leaflets were resected while the sewing cuff was retained on the annulus. A 23-mm Carbomedics OptiForm valve was implanted onto the sewing cuff. The patient’s postoperative course was good with no MS or MR. He was discharged on the 15th postoperative day.
Department of Cardiovascular Surgery, Seirei Hamamatsu General Hospital, Hamamatsu, Japan Corresponding author: Satoshi Miyairi, MD, Department of Cardiovascular Surgery, Seirei Hamamatsu General Hospital, 2-12-12, Sumiyoshi, Naka-ku, Hamamatsu-City, Shizuoka 430-8558, Japan. Email: [email protected]
Downloaded from aan.sagepub.com at UNIV NEBRASKA LIBRARIES on January 9, 2016
708
Asian Cardiovascular & Thoracic Annals 23(6)
Case 2 A 66-year-old woman, who had undergone mitral commissurotomy for MS and MVR with a 29-mm IonescuShiley valve (Shiley, Inc., Irvine, CA, USA) at 30 and 36 years of age, presented to our hospital. Laboratory data indicated progressive hemolysis and anemia. Transthoracic echocardiography revealed severe MS, trivial MR, and an enlarged left atrium. We diagnosed the patient with heart failure and primary tissue failure of the mitral bioprosthesis, and scheduled surgery. We performed redo MVR using a 25-mm Carbomedics OptiForm valve. After a repeat median sternotomy, synechiotomy, and cardiopulmonary bypass establishment, the mitral bioprosthesis was examined through a right-sided left atriotomy. The annulus was largely covered with intima, and the bioprosthesis leaflets had become rigid and fragile. Because the artificial valve was firmly attached to the mitral annulus and its stent post had become embedded in the left ventricular posterior wall, only the leaflets were removed. A 25-mm Carbomedics OptiForm valve was sutured onto the sewing cuff. The postoperative course was uneventful with no MS or MR, and the patient was discharged on the 14th postoperative day.
Discussion Bioprosthetic degeneration including primary tissue failure is the most common reason for reoperation.1 The risk associated with mitral valve redo operations is high. Firm adhesion to the mitral annulus or embedding of the stent post in the left ventricular wall makes valve removal difficult. Removal of such adhesion or calcification may cause postoperative left ventricular rupture or paravalvular leak. Geha and colleagues1 reported good outcomes from 34 valve-on-valve cases. Stassano and colleagues2 also reported successful midterm outcomes with the valveon-valve technique. Shibata and colleagues3 described the suitability of valves for this method. We also previously reported a case of valve-on-valve replacement.4 We opted for the valve-on-valve method with the Carbomedics OptiForm mechanical valve. The OptiForm valve is the most suitable valve for valveon-valve replacement, in terms of profile and size.3 Moreover, the OptiForm valve is superior in terms of fitting to the sewing cuff of the previous bioprosthesis. Because the OptiForm sewing cuff is soft and has a center top shape, it can be fitted firmly to the old sewing cuff. We devised a method to suture the new valve to the old bioprosthesis, wherein pledgeted mattress sutures are applied to the previous sewing cuff, and the needles are passed through the OptiForm sewing cuff from the bottom, emerging at the side of
the top of the OptiForm cuff (Figure 1). Thus the OptiForm sewing cuff fits firmly onto the old sewing ring (Figure 2). In case 1, because a 25-mm mechanical mitral prosthesis had been used previously, the body
Figure 1. Pledgeted mattress sutures were applied to the sewing cuff of the previous bioprosthesis, and the needles were passed through the sewing cuff of the Carbomedics OptiForm valve, from the bottom to the side of the top of the cuff (arrow).
Figure 2. The sewing cuff of the Carbomedics OptiForm valve is soft, and the sutured cuff fits well on the previous sewing ring (arrow).
Downloaded from aan.sagepub.com at UNIV NEBRASKA LIBRARIES on January 9, 2016
Miyairi et al.
709
surface area was 1.34 m2, and marked calcification was present around the mitral annulus including the left atrium, we opted for a 23-mm OptiForm valve for redo MVR via the valve-on-valve method. No poor seating or leak was observed, and an excellent hemodynamic outcome was obtained. We concluded that the valve-on-valve method is appropriate for avoiding left ventricular rupture or a major paravalvular leak in cases of redo mitral valve replacement. Moreover, good results were obtained. Funding This research received no specific grant from any funding agency in the public, commerical, or not-for-profit sectors.
References 1. Geha AS, Massad MG and Snow NJ. Replacement of degenerated mitral and aortic bioprostheses without explantation. Ann Thorac Surg 2001; 72: 1509–1514. 2. Stassano P, Musumeci A, Losi MA, Gagliardi C and Spampinato N. Mid-term results of the valve-on-valve technique for bioprosthetic failure. Eur J Cardiothorac Surg 2000; 18: 453–457. 3. Shibata T, Inoue K, Ikuta T, Bito Y, Yoshioka Y and Mizoguchi H. Which valve and which size should we use in the valve-on-valve technique for re-do mitral valve surgery? Interact Cardiovasc Thorac Surg 2009; 8: 206–210. 4. Tateishi M, Koide M, Kunii Y, Watanabe K and Ohsawa M. Valve-in-valve replacement of primary tissue valve failure of bovine pericardial valve minor. Kyobu Geka 2006; 59: 61–64.
Conflict of interest statement None declared.
Downloaded from aan.sagepub.com at UNIV NEBRASKA LIBRARIES on January 9, 2016
