318
FEATURE ARTICLES
CASE REPORT YAMANE ET AL AORTIC AND MITRAL TRANSCATHETER VALVE-IN-VALVE
Ann Thorac Surg 2014;98:318–21
strategy succeeded, they did not describe the source of the renal insufficiency or the status of postoperative renal function. Our patient had undergone antihypertensive therapy because of a cerebral hemorrhage caused by hypertension in the upper extremities. Consequently, renal insufficiency might have gradually advanced because of hypotension in the lower half of the body. Preoperative CT showed that the size of the bilateral kidneys was essentially normal. Thus, postoperative renal function was probably improved by increasing renal blood flow. Management of the massive thoracic collateral aneurysm then became the essential focus for this patient. Although a similar patient with an IAA and a descending thoracic aortic aneurysm has been described, that patient was treated only by an extraanatomical bypass through a left thoracotomy without resection of the aneurysm [6]. However, the collateral thoracic aneurysm in our patient arose from a branch of the suprascapular artery. Because the collateral arteries in patients with IAA can rupture spontaneously [7], resection of the thoracic aneurysm should have been the absolute option for our patient. In fact, pathologic findings of the thoracic aneurysmal wall extracted during the operation indicated a fractured lamina elastica interna and tunica media. Therefore, we supposed that the thoracic collateral aneurysm was in a state of imminent preoperative rupture. Besides, the diameter of the remaining multiple abdominal collateral aneurysms required periodic monitoring. Most surgeons seem to select a bypass from the ascending to the descending aorta through a median sternotomy to facilitate cardiopulmonary bypass with cardiac arrest and complex cardiac surgical procedures to treat IAA [2, 7]. However, we resected the massive thoracic aneurysm through a left posterolateral thoracotomy. Furthermore, an extraanatomical bypass without cardiopulmonary bypass was feasible for the abundant collateral arteries. Clamping the left subclavian artery set blood pressure in the right radial artery relatively high to generate a mean femoral artery pressure of more than 40 mm Hg [1, 8]. We preserved the intercostal arteries by partially clamping the descending aorta [3]. These strategies resulted in an uneventful majorevent–free postoperative course. We successfully resected a massive thoracic collateral aneurysm, constructed a bypass from the left subclavian artery to the descending aorta, and normalized postoperative renal function in an adult patient with very rare IAA and multiple abdominal collateral aneurysms; however, the remaining multiple abdominal collateral aneurysms required careful monitoring.
4. Cao YH, Zhang GY, Han JL. Isolated interrupted aortic arch complicated by subarachnoid hemorrhage in an adult patient. Neurol India 2009;57:806–7. 5. Sakellaridis T, Argiriou M, Panagiotakopoulos V, et al. Latent congenital defect: interrupted aortic arch in an adult—case report and literature review. Vasc Endovascular Surg 2010;44: 402–6. 6. Yu W, Chen CJ, Wang X, et al. Interrupted aortic arch accompanied by a giant saccular aneurysm in a 53-year-old man. Eur J Echocardiogr 2011;12:909. 7. Sai Krishna C, Bhan A, Sharma S, et al. Interruption of aortic arch in adults: surgical experience with extra-anatomic bypass. Tex Heart Inst J 2005;32:147–50. 8. Backer CL, Stewart RD, Kelle AM, et al. Use of partial cardiopulmonary bypass for coarctation repair through a left thoracotomy in children without collaterals. Ann Thorac Surg 2006;82:964–72.
Transcatheter Valve-in-Valve Implantation for Early Prosthetic Valve Degeneration in Aortic and Mitral Positions Kentaro Yamane, MD, PhD, Tamim M. Nazif, MD, Omar Khalique, MD, Rebecca T. Hahn, MD, Martin B. Leon, MD, Susheel K. Kodali, MD, Mathew R. Williams, MD, and Isaac George, MD Division of Cardiothoracic Surgery, Department of Surgery, and Division of Cardiology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York
Recently, transcatheter valve-in-valve implantation has emerged as a new alternative to surgical reoperation for degenerated bioprosthetic valves, either in the aortic or mitral position. The early experience and outcome of this strategy appears promising in highly selected patient groups. Here we report a case of early structural valve degeneration in the aortic and mitral position in a patient with chronic hemodialysis successfully treated with transthoracic transcatheter valve-in-valve implantation. (Ann Thorac Surg 2014;98:318–21) Ó 2014 by The Society of Thoracic Surgeons
P
atients with end-stage renal disease (ESRD) on chronic hemodialysis (HD) undergoing cardiac surgery carry a high risk of perioperative morbidity, a poor long-term prognosis, and the risk of early structural valve degeneration (SVD) due to impaired calcium metabolism. The operative risk in this cohort more than doubles if the Accepted for publication Sept 10, 2013.
References 1. Gordon EA, Person T, Kavarana M, et al. Interrupted aortic arch in the adult. J Card Surg 2011;26:405–9. 2. Lafci G, Yalcinkaya A, Ecevit AN, et al. Single-stage aortic valve-sparing root replacement. Tex Heart Inst J 2012;39: 398–400. 3. Ogino H, Miki S, Matsubayashi K, et al. Two-stage repair for aortic regurgitation with interrupted aortic arch. Ann Thorac Surg 1998;65:1151–3. Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier Inc
Address correspondence to Dr George, Division of Cardiothoracic Surgery, New York Presbyterian Hospital, College of Physicians and Surgeons of Columbia University, Milstein Hospital Building, 7GN-435, 177 Fort Washington Ave, New York, NY 10032; e-mail: ig2006@ columbia.edu.
Drs Kodali and Williams disclose financial relationships with Edwards Lifesciences.
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2013.09.061
CASE REPORT YAMANE ET AL AORTIC AND MITRAL TRANSCATHETER VALVE-IN-VALVE
patient requires reoperation for SVD in multiple valve positions [1]. Recently, transcatheter valve-in-valve implantation (TVIV) has emerged as a new alternative to surgical reoperation for degenerated bioprosthetic valves, either in aortic or mitral position (AV, MV) [2, 3]. The early experience and outcome of this strategy appears promising in highly selected patient groups. Here we report a case of early SVD in the aortic and mitral position in a patient with chronic hemodialysis successfully treated with transthoracic TVIV.
progressive calcification. After discussion among the patient, multiple surgeons, and heart valve team, it was decided to undergo concomitant aortic and mitral TVIV through a transapical approach, followed by parathyroid surgery to prevent repeated SVD. In the hybrid operating room, his valve sizes were confirmed with TEE. A small left anterolateral thoracotomy incision was made, and the left ventricular (LV) apex was exposed. Two 2-0 Prolene purse strings with felt pledgets were placed in the LV apex in preparation for LV apical access. It was decided to perform the AV-transcatheter aortic valve replacement first, in order to minimize possible balloon interference with protruding MV commissural posts. The LV apex was accessed with an 18 G needle and a soft stiff wire was advanced to the descending aorta. The 26 Fr Retroflex 3 device sheath was advanced over this stiff wire. A 23-mm Edwards SAPIEN balloon expandable valve (Edwards Lifesciences, Irvine, CA) was loaded over the stiff wire and maneuvered across the aortic bioprosthesis. Correct positioning was confirmed by both transesophageal echo and by angiography, and then, under rapid pacing, the valve was deployed with an 80:20 aortic to LV configuration (Fig 2), with the valve skirt covering the sewing ring. Next, after removal of the first device, the stenotic mitral bioprosthesis was then carefully crossed with a soft wire and cardiopulmonary bypass was started through the femoral artery and vein in order to support hemodynamics and empty the heart. A stiff wire was placed in the left atrium and the valve was advanced across the mitral bioprosthesis. After proper positioning, a 26-mm Edwards SAPIEN valve was deployed under rapid pacing (Fig 3) using similarly described positioning. No paravalvular leak was noted on post-procedure TEE, and the patient was successfully extubated at the conclusion of the procedure. The postoperative course was uneventful and the patient discharged to home on the seventh day after the procedure.
The patient is a 34-year-old man with a past medical history of hypertension, ESRD on chronic hemodialysis, and peptic ulcer disease. The patient developed methicillinsensitive Staphylococcus aureus and methicillin-resistant Staphylococcus aureus endocarditis with multiple septic emboli to the brain accompanied with tonic-clonic seizures. Subsequently, the patient underwent an AV and MV replacement using 21-mm and 25-mm bovine tissue valves, and mitral annular reconstruction using bovine pericardium. Three months after initial surgery, he developed shortness of breath and decreased exercise tolerance. One month later, he visited our emergency department for even worsening shortness of breath and orthopnea. Transthoracic and transesophageal echocardiogram (TEE) showed thickened and immobile aortic cusps with a peak gradient of 79.6 mm Hg, mean gradient of 56.4 mm Hg, and AV area of 0.8 cm2. His mitral bioprosthesis was also markedly thickened with only 1 mobile leaflet and had an elevated mean gradient of 24 mm Hg with MV area of 0.85 cm2 (Fig 1); no paravalvular leak was present, and there was no clinical evidence of recurrent endocarditis. His systolic function was mildly decreased. Because of his comorbidities and recent surgery, he was deemed at extremely high risk for reoperative valve surgery, and other options were entertained. In addition, he was found during his workup to have a parathyroid adenoma that likely contributed to his
Fig 1. Transesophageal echocardiogram showing severe calcific degeneration of the bioprosthesis in the (A) aortic position and the (B) mitral position.
FEATURE ARTICLES
319
Ann Thorac Surg 2014;98:318–21
320
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FEATURE ARTICLES
Fig 2. A 23-mm Edwards SAPIEN balloon expandable valve in the aortic bioprosthesis. (A) pre-deployment and (B) post-deployment.
Comment The ESRD patients on chronic HD undergoing cardiac surgery are known to have higher perioperative comorbidity rate and poor operative as well as long-term survival, compared with non-dialysis patients. The risk of mortality is even higher for those with endocarditis, reoperation, multiple valve surgery, surgery SVD, or for heart failure symptoms [1]. Based on this, and additional high likelihood of perioperative complications such as bleeding, prolonged ventilation, bacteremia, endocarditis, and mediastinitis, we decided to proceed with TVIV through transapical access after confirming no evidence of active prosthetic valve endocarditis. Transcatheter valve-in-valve for SVD has been increasingly applied to selected patient groups for both aortic and mitral positions [2, 3]. Dvir and colleagues [2] reviewed the Global Valve-in-Valve registry and found reasonable procedural success rate of 93.1% in 202 patients with 30day all-cause mortality of 8.4% and 1-year survival rate of 85.8% for AV-TVIV. For the mitral position, Cheung and colleagues [3] reported their experience in 23 transapical mitral TVIV using Edwards SAPIEN balloon expandable valves. One patient suffered atrial migration of the SAPIEN valve, which was successfully managed
Ann Thorac Surg 2014;98:318–21
Fig 3. A 26-mm Edwards SAPIEN balloon expandable valve in the mitral bioprosthesis. (A) Pre-deployment and (B) post-deployment.
with reintervention. At median follow-up of 753 days, overall survival rate was 90.4% [3]. Even though high post-procedural gradients are relatively common in aortic TVIV, improved mean aortic valve gradients and New York Heart Association functional class have been confirmed in multiple studies [2, 3]. The mechanism of calcific degeneration of bioprosthetic material has been investigated in various animal models. Cellular and humoral rejection to xenograft material has been reported, which correlates with calcification of glutaraldehyde-fixed bioprosthetic tissue in small animals [4]. In the clinical setting, altered calcium metabolism in ESRD patients is also thought to be related to early calcification of the bioprosthetic valve. Therefore, risks of open surgical approach, anticoagulation, reinfection, and factors such as life expectancy of the patient and the patient’s preference for valve type, are all vital upon making the decision to choose this approach for concomitant aortic and mitral TVIV. Although the experience is limited at this point, transapical TVIV for early aortic and mitral SVD may be a feasible and preferred option with acceptable early outcomes in patients deemed at extremely high risk for conventional surgery.
CASE REPORT ROHN ET AL PERICARDIAL VALVE DETERIORATION FROM ADHESIONS
References
We report a case of a 71-year old patient with significant SVD of a mitral pericardial valve prosthesis caused by fusion of the prosthetic leaflet and the retained native posterior mitral leaflet.
1. Yamane K, Hirose H, Bogar LJ, Cavarocchi NC, Diehl JT. Surgical treatment of infective endocarditis in patients undergoing chronic hemodialysis. J Heart Valve Dis 2012;21: 774–82. 2. Dvir D, Webb J, Brecker S, et al. Transcatheter aortic valve replacement for degenerative bioprosthetic surgical valves: results from the global valve-in-valve registry. Circulation 2012;126:2335–44. 3. Cheung A, Webb JG, Barbanti M, et al. 5-Year Experience With Transcatheter Transapical Mitral Valve-in-Valve Implantation for Bioprosthetic Valve Dysfunction. J Am Coll Cardiol 2013;61:1759–66. 4. Manji RA, Zhu LF, Nijjar NK, et al. Glutaraldehyde-fixed bioprosthetic heart valve conduits calcify and fail from xenograft rejection. Circulation 2006;114:318–27.
Early Pericardial Valve Deterioration as a Result of Adhesions With Native Mitral Valve Vilem Rohn, MD, PhD, Miroslav Spacek, MD, Robert Sachl, MD, and Ivana Vitkova, MD, MBA 2nd Department of Surgery, Department of Cardiovascular Surgery, Department of Anaesthesiology, Resuscitation and Intensive Medicine, and Institute of Pathology, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Prague, Czech Republic
We report an unusual case of early pericardial tissue valve prosthesis deterioration that required replacement. Four years after mitral valve replacement, 1 of the 3 leaflets of the valve was thickened and retracted in a fixed open position, which resulted in severe mitral insufficiency. The cause of this was adhesion of the leaflet and the patient’s own retained posterior mitral valve leaflet. The finding was confirmed at operation and by histologic examination. (Ann Thorac Surg 2014;98:321–3) Ó 2014 by The Society of Thoracic Surgeons
A 68-year-old woman patient underwent mitral valve replacement with a pericardial prosthesis (27-mm Carpentier-Edwards PERIMOUNT, Edwards Lifesciences, Irvine, CA) 4 years previously. The postoperative course was uneventful and she recovered well. She was regularly followed by a cardiologist and improved functionally from New York Heart Association class III to New York Heart Association class I. In the past year, however, shortness of breath reappeared. On echocardiography, intraprosthetic mitral regurgitation was detected. The patient was then referred to our center. On admission, examinations with transthoracic and transesophageal echocardiography were performed. Both revealed mitral regurgitation grade 4þ, functional tricuspid regurgitation 3þ, with a dilated annulus and severely dilated atria. She also had atrial fibrillation. A redo operation was indicated. During the operation, we found that 1 leaflet of the prosthesis adjacent to the original posterior leaflet of the mitral valve was stiff, immobile, and a little short. Macroscopically, there were no signs of infection. We removed the prosthesis and found that the retained original posterior leaflet was firmly healed with the valve replacement (Figs 1, 2). Replacement of the mitral valve with a porcine bioprosthesis, tricuspid valve annuloplasty with a flexible ring, and resection and suturing of the left atrial appendage was performed. Histologic examination confirmed our suspicion that there were adhesions of both leaflets (native and prosthetic) and consequently their accelerated degeneration (Fig 3). Six months later, the patient is doing well, with no dyspnea. The echocardiographic findings on both operated valves are normal.
T
he pericardial heart valve was invented by Ionescu and colleagues in the early 1970s [1]. Since then, bovine pericardial tissue valves have been used with excellent hemodynamic results. They are the preferred prostheses in elderly patients because of their hemodynamic performance and reduced bleeding complications from short-term anticoagulation therapy [2]. Structural valve deterioration (SVD) represents the major limitation to their use in patients with longer life expectancy. However, patients aged 65 years and older had a less than 10% chance of explantation for SVD by 15 years after implantation [3].
Accepted for publication Sept 5, 2013. Address correspondence to Dr Rohn, 2nd Department of Surgery, Department of Cardiovascular Surgery, Charles University in Prague and General University Hospital in Prague, Czech Republic, U Nemocnice 2, 128 00 Praha 2, Czech Republic; e-mail: [email protected].
Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier Inc
Fig 1. Prosthesis with 1 leaflet retracted was removed (view from the left atrium). 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2013.09.027
FEATURE ARTICLES
321
Ann Thorac Surg 2014;98:321–3
FEATURE ARTICLES
CASE REPORT YAMANE ET AL AORTIC AND MITRAL TRANSCATHETER VALVE-IN-VALVE
Ann Thorac Surg 2014;98:318–21
strategy succeeded, they did not describe the source of the renal insufficiency or the status of postoperative renal function. Our patient had undergone antihypertensive therapy because of a cerebral hemorrhage caused by hypertension in the upper extremities. Consequently, renal insufficiency might have gradually advanced because of hypotension in the lower half of the body. Preoperative CT showed that the size of the bilateral kidneys was essentially normal. Thus, postoperative renal function was probably improved by increasing renal blood flow. Management of the massive thoracic collateral aneurysm then became the essential focus for this patient. Although a similar patient with an IAA and a descending thoracic aortic aneurysm has been described, that patient was treated only by an extraanatomical bypass through a left thoracotomy without resection of the aneurysm [6]. However, the collateral thoracic aneurysm in our patient arose from a branch of the suprascapular artery. Because the collateral arteries in patients with IAA can rupture spontaneously [7], resection of the thoracic aneurysm should have been the absolute option for our patient. In fact, pathologic findings of the thoracic aneurysmal wall extracted during the operation indicated a fractured lamina elastica interna and tunica media. Therefore, we supposed that the thoracic collateral aneurysm was in a state of imminent preoperative rupture. Besides, the diameter of the remaining multiple abdominal collateral aneurysms required periodic monitoring. Most surgeons seem to select a bypass from the ascending to the descending aorta through a median sternotomy to facilitate cardiopulmonary bypass with cardiac arrest and complex cardiac surgical procedures to treat IAA [2, 7]. However, we resected the massive thoracic aneurysm through a left posterolateral thoracotomy. Furthermore, an extraanatomical bypass without cardiopulmonary bypass was feasible for the abundant collateral arteries. Clamping the left subclavian artery set blood pressure in the right radial artery relatively high to generate a mean femoral artery pressure of more than 40 mm Hg [1, 8]. We preserved the intercostal arteries by partially clamping the descending aorta [3]. These strategies resulted in an uneventful majorevent–free postoperative course. We successfully resected a massive thoracic collateral aneurysm, constructed a bypass from the left subclavian artery to the descending aorta, and normalized postoperative renal function in an adult patient with very rare IAA and multiple abdominal collateral aneurysms; however, the remaining multiple abdominal collateral aneurysms required careful monitoring.
4. Cao YH, Zhang GY, Han JL. Isolated interrupted aortic arch complicated by subarachnoid hemorrhage in an adult patient. Neurol India 2009;57:806–7. 5. Sakellaridis T, Argiriou M, Panagiotakopoulos V, et al. Latent congenital defect: interrupted aortic arch in an adult—case report and literature review. Vasc Endovascular Surg 2010;44: 402–6. 6. Yu W, Chen CJ, Wang X, et al. Interrupted aortic arch accompanied by a giant saccular aneurysm in a 53-year-old man. Eur J Echocardiogr 2011;12:909. 7. Sai Krishna C, Bhan A, Sharma S, et al. Interruption of aortic arch in adults: surgical experience with extra-anatomic bypass. Tex Heart Inst J 2005;32:147–50. 8. Backer CL, Stewart RD, Kelle AM, et al. Use of partial cardiopulmonary bypass for coarctation repair through a left thoracotomy in children without collaterals. Ann Thorac Surg 2006;82:964–72.
Transcatheter Valve-in-Valve Implantation for Early Prosthetic Valve Degeneration in Aortic and Mitral Positions Kentaro Yamane, MD, PhD, Tamim M. Nazif, MD, Omar Khalique, MD, Rebecca T. Hahn, MD, Martin B. Leon, MD, Susheel K. Kodali, MD, Mathew R. Williams, MD, and Isaac George, MD Division of Cardiothoracic Surgery, Department of Surgery, and Division of Cardiology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York
Recently, transcatheter valve-in-valve implantation has emerged as a new alternative to surgical reoperation for degenerated bioprosthetic valves, either in the aortic or mitral position. The early experience and outcome of this strategy appears promising in highly selected patient groups. Here we report a case of early structural valve degeneration in the aortic and mitral position in a patient with chronic hemodialysis successfully treated with transthoracic transcatheter valve-in-valve implantation. (Ann Thorac Surg 2014;98:318–21) Ó 2014 by The Society of Thoracic Surgeons
P
atients with end-stage renal disease (ESRD) on chronic hemodialysis (HD) undergoing cardiac surgery carry a high risk of perioperative morbidity, a poor long-term prognosis, and the risk of early structural valve degeneration (SVD) due to impaired calcium metabolism. The operative risk in this cohort more than doubles if the Accepted for publication Sept 10, 2013.
References 1. Gordon EA, Person T, Kavarana M, et al. Interrupted aortic arch in the adult. J Card Surg 2011;26:405–9. 2. Lafci G, Yalcinkaya A, Ecevit AN, et al. Single-stage aortic valve-sparing root replacement. Tex Heart Inst J 2012;39: 398–400. 3. Ogino H, Miki S, Matsubayashi K, et al. Two-stage repair for aortic regurgitation with interrupted aortic arch. Ann Thorac Surg 1998;65:1151–3. Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier Inc
Address correspondence to Dr George, Division of Cardiothoracic Surgery, New York Presbyterian Hospital, College of Physicians and Surgeons of Columbia University, Milstein Hospital Building, 7GN-435, 177 Fort Washington Ave, New York, NY 10032; e-mail: ig2006@ columbia.edu.
Drs Kodali and Williams disclose financial relationships with Edwards Lifesciences.
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2013.09.061
CASE REPORT YAMANE ET AL AORTIC AND MITRAL TRANSCATHETER VALVE-IN-VALVE
patient requires reoperation for SVD in multiple valve positions [1]. Recently, transcatheter valve-in-valve implantation (TVIV) has emerged as a new alternative to surgical reoperation for degenerated bioprosthetic valves, either in aortic or mitral position (AV, MV) [2, 3]. The early experience and outcome of this strategy appears promising in highly selected patient groups. Here we report a case of early SVD in the aortic and mitral position in a patient with chronic hemodialysis successfully treated with transthoracic TVIV.
progressive calcification. After discussion among the patient, multiple surgeons, and heart valve team, it was decided to undergo concomitant aortic and mitral TVIV through a transapical approach, followed by parathyroid surgery to prevent repeated SVD. In the hybrid operating room, his valve sizes were confirmed with TEE. A small left anterolateral thoracotomy incision was made, and the left ventricular (LV) apex was exposed. Two 2-0 Prolene purse strings with felt pledgets were placed in the LV apex in preparation for LV apical access. It was decided to perform the AV-transcatheter aortic valve replacement first, in order to minimize possible balloon interference with protruding MV commissural posts. The LV apex was accessed with an 18 G needle and a soft stiff wire was advanced to the descending aorta. The 26 Fr Retroflex 3 device sheath was advanced over this stiff wire. A 23-mm Edwards SAPIEN balloon expandable valve (Edwards Lifesciences, Irvine, CA) was loaded over the stiff wire and maneuvered across the aortic bioprosthesis. Correct positioning was confirmed by both transesophageal echo and by angiography, and then, under rapid pacing, the valve was deployed with an 80:20 aortic to LV configuration (Fig 2), with the valve skirt covering the sewing ring. Next, after removal of the first device, the stenotic mitral bioprosthesis was then carefully crossed with a soft wire and cardiopulmonary bypass was started through the femoral artery and vein in order to support hemodynamics and empty the heart. A stiff wire was placed in the left atrium and the valve was advanced across the mitral bioprosthesis. After proper positioning, a 26-mm Edwards SAPIEN valve was deployed under rapid pacing (Fig 3) using similarly described positioning. No paravalvular leak was noted on post-procedure TEE, and the patient was successfully extubated at the conclusion of the procedure. The postoperative course was uneventful and the patient discharged to home on the seventh day after the procedure.
The patient is a 34-year-old man with a past medical history of hypertension, ESRD on chronic hemodialysis, and peptic ulcer disease. The patient developed methicillinsensitive Staphylococcus aureus and methicillin-resistant Staphylococcus aureus endocarditis with multiple septic emboli to the brain accompanied with tonic-clonic seizures. Subsequently, the patient underwent an AV and MV replacement using 21-mm and 25-mm bovine tissue valves, and mitral annular reconstruction using bovine pericardium. Three months after initial surgery, he developed shortness of breath and decreased exercise tolerance. One month later, he visited our emergency department for even worsening shortness of breath and orthopnea. Transthoracic and transesophageal echocardiogram (TEE) showed thickened and immobile aortic cusps with a peak gradient of 79.6 mm Hg, mean gradient of 56.4 mm Hg, and AV area of 0.8 cm2. His mitral bioprosthesis was also markedly thickened with only 1 mobile leaflet and had an elevated mean gradient of 24 mm Hg with MV area of 0.85 cm2 (Fig 1); no paravalvular leak was present, and there was no clinical evidence of recurrent endocarditis. His systolic function was mildly decreased. Because of his comorbidities and recent surgery, he was deemed at extremely high risk for reoperative valve surgery, and other options were entertained. In addition, he was found during his workup to have a parathyroid adenoma that likely contributed to his
Fig 1. Transesophageal echocardiogram showing severe calcific degeneration of the bioprosthesis in the (A) aortic position and the (B) mitral position.
FEATURE ARTICLES
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Ann Thorac Surg 2014;98:318–21
320
CASE REPORT YAMANE ET AL AORTIC AND MITRAL TRANSCATHETER VALVE-IN-VALVE
FEATURE ARTICLES
Fig 2. A 23-mm Edwards SAPIEN balloon expandable valve in the aortic bioprosthesis. (A) pre-deployment and (B) post-deployment.
Comment The ESRD patients on chronic HD undergoing cardiac surgery are known to have higher perioperative comorbidity rate and poor operative as well as long-term survival, compared with non-dialysis patients. The risk of mortality is even higher for those with endocarditis, reoperation, multiple valve surgery, surgery SVD, or for heart failure symptoms [1]. Based on this, and additional high likelihood of perioperative complications such as bleeding, prolonged ventilation, bacteremia, endocarditis, and mediastinitis, we decided to proceed with TVIV through transapical access after confirming no evidence of active prosthetic valve endocarditis. Transcatheter valve-in-valve for SVD has been increasingly applied to selected patient groups for both aortic and mitral positions [2, 3]. Dvir and colleagues [2] reviewed the Global Valve-in-Valve registry and found reasonable procedural success rate of 93.1% in 202 patients with 30day all-cause mortality of 8.4% and 1-year survival rate of 85.8% for AV-TVIV. For the mitral position, Cheung and colleagues [3] reported their experience in 23 transapical mitral TVIV using Edwards SAPIEN balloon expandable valves. One patient suffered atrial migration of the SAPIEN valve, which was successfully managed
Ann Thorac Surg 2014;98:318–21
Fig 3. A 26-mm Edwards SAPIEN balloon expandable valve in the mitral bioprosthesis. (A) Pre-deployment and (B) post-deployment.
with reintervention. At median follow-up of 753 days, overall survival rate was 90.4% [3]. Even though high post-procedural gradients are relatively common in aortic TVIV, improved mean aortic valve gradients and New York Heart Association functional class have been confirmed in multiple studies [2, 3]. The mechanism of calcific degeneration of bioprosthetic material has been investigated in various animal models. Cellular and humoral rejection to xenograft material has been reported, which correlates with calcification of glutaraldehyde-fixed bioprosthetic tissue in small animals [4]. In the clinical setting, altered calcium metabolism in ESRD patients is also thought to be related to early calcification of the bioprosthetic valve. Therefore, risks of open surgical approach, anticoagulation, reinfection, and factors such as life expectancy of the patient and the patient’s preference for valve type, are all vital upon making the decision to choose this approach for concomitant aortic and mitral TVIV. Although the experience is limited at this point, transapical TVIV for early aortic and mitral SVD may be a feasible and preferred option with acceptable early outcomes in patients deemed at extremely high risk for conventional surgery.
CASE REPORT ROHN ET AL PERICARDIAL VALVE DETERIORATION FROM ADHESIONS
References
We report a case of a 71-year old patient with significant SVD of a mitral pericardial valve prosthesis caused by fusion of the prosthetic leaflet and the retained native posterior mitral leaflet.
1. Yamane K, Hirose H, Bogar LJ, Cavarocchi NC, Diehl JT. Surgical treatment of infective endocarditis in patients undergoing chronic hemodialysis. J Heart Valve Dis 2012;21: 774–82. 2. Dvir D, Webb J, Brecker S, et al. Transcatheter aortic valve replacement for degenerative bioprosthetic surgical valves: results from the global valve-in-valve registry. Circulation 2012;126:2335–44. 3. Cheung A, Webb JG, Barbanti M, et al. 5-Year Experience With Transcatheter Transapical Mitral Valve-in-Valve Implantation for Bioprosthetic Valve Dysfunction. J Am Coll Cardiol 2013;61:1759–66. 4. Manji RA, Zhu LF, Nijjar NK, et al. Glutaraldehyde-fixed bioprosthetic heart valve conduits calcify and fail from xenograft rejection. Circulation 2006;114:318–27.
Early Pericardial Valve Deterioration as a Result of Adhesions With Native Mitral Valve Vilem Rohn, MD, PhD, Miroslav Spacek, MD, Robert Sachl, MD, and Ivana Vitkova, MD, MBA 2nd Department of Surgery, Department of Cardiovascular Surgery, Department of Anaesthesiology, Resuscitation and Intensive Medicine, and Institute of Pathology, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Prague, Czech Republic
We report an unusual case of early pericardial tissue valve prosthesis deterioration that required replacement. Four years after mitral valve replacement, 1 of the 3 leaflets of the valve was thickened and retracted in a fixed open position, which resulted in severe mitral insufficiency. The cause of this was adhesion of the leaflet and the patient’s own retained posterior mitral valve leaflet. The finding was confirmed at operation and by histologic examination. (Ann Thorac Surg 2014;98:321–3) Ó 2014 by The Society of Thoracic Surgeons
A 68-year-old woman patient underwent mitral valve replacement with a pericardial prosthesis (27-mm Carpentier-Edwards PERIMOUNT, Edwards Lifesciences, Irvine, CA) 4 years previously. The postoperative course was uneventful and she recovered well. She was regularly followed by a cardiologist and improved functionally from New York Heart Association class III to New York Heart Association class I. In the past year, however, shortness of breath reappeared. On echocardiography, intraprosthetic mitral regurgitation was detected. The patient was then referred to our center. On admission, examinations with transthoracic and transesophageal echocardiography were performed. Both revealed mitral regurgitation grade 4þ, functional tricuspid regurgitation 3þ, with a dilated annulus and severely dilated atria. She also had atrial fibrillation. A redo operation was indicated. During the operation, we found that 1 leaflet of the prosthesis adjacent to the original posterior leaflet of the mitral valve was stiff, immobile, and a little short. Macroscopically, there were no signs of infection. We removed the prosthesis and found that the retained original posterior leaflet was firmly healed with the valve replacement (Figs 1, 2). Replacement of the mitral valve with a porcine bioprosthesis, tricuspid valve annuloplasty with a flexible ring, and resection and suturing of the left atrial appendage was performed. Histologic examination confirmed our suspicion that there were adhesions of both leaflets (native and prosthetic) and consequently their accelerated degeneration (Fig 3). Six months later, the patient is doing well, with no dyspnea. The echocardiographic findings on both operated valves are normal.
T
he pericardial heart valve was invented by Ionescu and colleagues in the early 1970s [1]. Since then, bovine pericardial tissue valves have been used with excellent hemodynamic results. They are the preferred prostheses in elderly patients because of their hemodynamic performance and reduced bleeding complications from short-term anticoagulation therapy [2]. Structural valve deterioration (SVD) represents the major limitation to their use in patients with longer life expectancy. However, patients aged 65 years and older had a less than 10% chance of explantation for SVD by 15 years after implantation [3].
Accepted for publication Sept 5, 2013. Address correspondence to Dr Rohn, 2nd Department of Surgery, Department of Cardiovascular Surgery, Charles University in Prague and General University Hospital in Prague, Czech Republic, U Nemocnice 2, 128 00 Praha 2, Czech Republic; e-mail: [email protected].
Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier Inc
Fig 1. Prosthesis with 1 leaflet retracted was removed (view from the left atrium). 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2013.09.027
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Ann Thorac Surg 2014;98:321–3
