Pannus overgrowth after mitral valve replacement with a Carpentier-Edwards pericardial bioprosthesis

A Carpentier-Edwards pericardial (CEP) bioprosthesis was explanted from an 81-year-old woman due to nonstructural dysfunction 9 years after mitral valve replacement. The nonstructural dysfunction produced severe regurgitation in the mitral position. During the surgery, excessive pannus overgrowth was seen on the left ventricular side of the CEP bioprosthesis. Pannus overgrowth was prominent on one leaflet. That leaflet was stiff and shortened due to the excessive overgrowth of pannus. In this patient, the distortion of one leaflet was the main reason for transvalvular leakage of the CEP bioprosthesis in the mitral position. A new CEP bioprosthesis was implanted in the mitral position. Pathological analysis revealed fibrotic pannus with a small amount of cellular material over the leaflets of the resected CEP valve. This change was marked on the distorted leaflet.     

Pannus formation in aortic valve prostheses in the late postoperative period

We present three patients who underwent repeat aortic valve replacement for prosthetic valve dysfunction caused by tissue ingrowth in the late postoperative period. These patients (three women aged 48–51 years, mean 49.3 ± 1.53 years) underwent operations for restriction of prosthetic valve leaflet movement by pannus in the left ventricular outflow tract. The interval from the previous operation ranged from 8.0 to 9.6 years (mean 9.6 ± 2.0 years). The symptoms of the patients were New York Heart Association functional class I, II, and IV in one patient each. Diagnosis was made by cinefluoroscopy in two patients and aortography in one patient. The operative procedures consisted of aortic valve replacement (n = 1) and aortic valve replacement with mitral valve replacement (n = 2). Pannus was found at the left ventricular aspect of the prosthetic valve in all patients. In two patients, the pannus directly restricted movement of the leaflet and also severely narrowed the inflow orifice of the prosthetic valve. In the other patient, the pannus had grown at a distance of 7mm from the valve and narrowed the left ventricular outflow tract circularly. The postoperative course was uneventful and all three patients were discharged in a good condition. One patient died of pneumonia 8 months after surgery and the other two patients have remained well and have been followed up for one and a half years. In conclusion, there may be a discrepancy between the clinical symptoms and the grade of subvalvular stenosis caused by pannus. Therefore, it is essential for satisfactory operative results that early diagnosis be made by various means.     

Severe complications following thrombolytic therapy of an acute thrombosis of a prosthetic mitral valve

Thrombosis of prosthetic cardiac valves is a rare but potentially lethal complication. As emergency surgical intervention of thrombotic prosthetic cardiac valves is correlated with high mortality, fibrinolytic therapy has been recently recommended as a therapy with high efficacy and no severe side effects. We report on a patient with thrombosis of a prosthetic mitral valve who developed severe embolic complications following the administration of the thrombolytic agent. On admission the patient showed signs of incipient cardiogenic shock. The diagnosis of thrombotic obstruction of the prosthetic mitral valve was confirmed by transesophageal echocardiography. The effective valve area was 0.41 cm². Pulmonary arterial blood pressure and wedge pressure were significantly elevated. A fibrinolytic therapy with recombinant tissue-type plasminogen activator according to the Neuhaus scheme was attempted. Within 60 min after start of treatment the effective valve area increased (1.41 cm²), and the pulmonary capillary wedge pressure decreased. However, peripheral and cerebral embolism occurred. Occlusion of the right brachial and right femoral artery was ascertained by Doppler ultrasound. Embolism into the right leg made an embolectomy with a Fogarty catheter necessary. Computed tomography revealed two lesions located in the occipital and left temporal area of the brain. Correlated with the lesions evaluated in computed tomography, right hemiplegia and complete aphasia was observed. The neurological status of the patient has only slightly improved to the present. To our knowledge no severe persistent neurological deficits following thrombolytic therapy have been reported. We therefore assume that the risk of severe neurological complications is underestimated. It is suggested that fibrinolytic therapy is a reasonable alternative in severely compromized patients with thrombotic prosthetic cardiac valves, but the final value of this treatment cannot be ascertained due to the small number of patients and the underestimation of severe embolic complications.Abbreviations PAP pulmonary arterial pressure - PCWP pulmonary capillary wedge pressure - rt-Pa recombinant tissue-type plasminogen activator Correspondence to: M.M. Hirschl     

Dysfunction of an ATS valve in the aortic position: the first reported case caused by pannus formation

A 64-year-old woman underwent aortic valve replacement with a 21-mm Advancing The Standard (ATS) open-pivot mechanical heart valve for bicuspid aortic valve stenosis. In addition to the appearance of a new cardiac murmur, echocardiography performed 3 years after surgery showed a high pressure gradient across the ATS valve and a reduction in the valve orifice area. Cineradiography of the valve revealed restricted leaflet opening. Subsequent multidetector-row computed tomography clearly demonstrated pannus overgrowth on the inflow aspect of the ATS valve. During a repeat operation, subvalvular overgrown pannus was confirmed and the ATS valve was replaced with a bioprosthetic valve. This is the first reported case of prosthetic valve dysfunction resulting from pannus formation in a patient with an ATS valve in the aortic position.     

国产久灵全热解碳双叶瓣跨瓣压差的研究

为了观察国产久灵全热解碳双叶瓣的跨瓣压差 ,对久灵瓣作了实验室流体力学进行流体力学测试。通过自编数据处理程序对参数进行自动分析。 2、动物实验测定 :手术中对置换 2 1m m型号二尖瓣的 6只羊用双导管法测定血流动力学 ;对 2只术后存活 2 .5年的羊先用超声法 ,然后用导管法并在多巴酚丁胺负荷下作血流动力学测定。 3、临床病人测定 :对 14例主动脉瓣和 10例二尖瓣用导管法和超声法测定。结果 :1、实验室测定 :测试瓣的Δ P,均随心率增加而减低 ,Δ P在 10 mm Hg以下。 2、动物实验 :术中 6只羊的ΔP,导管法 :5 .2± 1.7mm Hg。 2只术后 2 .5年羊的Δ P,超声法 :6 .8mm Hg。3、临床病人 :14例主动脉瓣ΔP,导管法 :6 .2 4～ 4 .10 mm Hg;超声法 :9.4 2～7.4 8mm Hg。二尖瓣Δ P,导管法 :2 .1～ 1.9m m Hg;超声法 :5 .3～ 4 .1mm Hg。结论 :国产久灵全热解碳双叶瓣平均跨瓣压差较低 ,具有良好的血流动力学效果     

Value of a modified continuity equation method to quantify mitral valve area in patients with mitral stenosis and sinus rhythm

Summary To quantify valve area in mitral stenosis, a modified continuity equation method using continuous wave Doppler and thermodilution measurements was applied. In 14 patients with mitral stenosis and sinus rhythm (age: 49±11 years), transmitral flow velocity was recorded by continuous wave Doppler during right and left heart catheterization. Mitral valve area was calculated by three different methods: 1. According to the continuity equation, stroke volume (thermodilution technique) was divided by the registered time velocity integral of the mitral stenotic jet (continuous wave Doppler). 2. Mitral valve area was calculated by the pressure half-time method. 3. Simultaneous pulmonary capillary wedge and left ventricular pressure measurements were used for determination of mitral valve area according to the Gorlin formula. The mitral valve area determined by application of the continuity equation (y) showed a close correlation to the valve area calculated by the Gorlin equation (x):y=0.73x+0.12, SEE=0.11 cm²,r=0.88,P<0.001. In contrast, the correlation between mitral valve area determined by pressure half-time (y) and the Gorlin formula (x) was not as good:y=0.77x+0.11, SEE=0.26 cm²,r=0.65,P<0.05. Thus, the continuity equation method using combined continuous wave Doppler and thermodilution technique allows a valid determination of mitral valve area. In patients with mitral stenosis and sinus rhythm, this technique is superior to the noninvasive determination of mitral valve area by the conventional pressure half-time method.Abbreviations bpm beats per minute - CO cardiac output - DFT diastolic filling time - HR heart rate - LV left ventricular - MMVG mean mitral valve gradient - MVA_CE mitral valve area determined according to the continuity equation method - MVA_G mitral valve area calculated according to the Gorlin formula - MVA_T1/2 mitral valve area determined according to the pressure half-time method - PCW pulmonary capillary wedge - SV stroke volume     

Novel "biomechanical" polymeric valve prostheses with special design for aortic and mitral position: a future option for pediatric patients?

In children, systemic heart valve replacement with bioprostheses is associated with accelerated valve degeneration, and mechanical prostheses require permanent anticoagulation. Novel "biomechanical" polymeric valve prostheses ("bio" = flexible, "mechanical" = synthetic), solely made of polycarbonate urethane (PCU), were tested in vitro and in a growing animal (calf) model with the aim of improved durability without permanent anticoagulation. The trileaflet aortic prosthesis has diminished pressure loss and reduced stress and strain peaks. The asymmetric bileaflet mitral valve mimics natural nonaxial inflow. The valves underwent long-term in vitro testing and in vivo testing in growing calves for 20 weeks [mitral (7), aortic (7)] with comparison to different commercial bioprostheses [mitral (7), aortic (2)]. In vitro durability of PCU valves was proved up to 20 years. Survival of PCU valves versus bioprostheses was 7 versus 2 mitral and 5 versus 0 aortic valves, respectively. Two animals with PCU aortic valves died of pannus overgrowth causing left ventricular outflow tract obstruction. Degeneration and calcification were mild (mitral) and moderate (aortic) in PCU valves but were severe in biological valves. There was no increased thrombogenicity of the PCU valves compared to bioprostheses. The novel polymeric valve prostheses revealed superior durability compared to current bioprostheses in growing animal model without permanent anticoagulation and thus, may be a future option for pediatric patients.     

Airway function disturbances reversibility after mitral valve replacement

Dyspnea, cough, recurrent airway infection, hemoptysis are the most common pulmonary symptoms of mitral valve disease and heart failure. Pathophysiological mechanism of those disturbances is complex and airway status is one of the most important. The aim of the study was to assess airway function disturbances reversibility after mitral valve replacement. The study group consisted of 30 patients qualified to mitral valve surgery. Patients were assessed by clinical cardiac noninvasive investigation and airway function study. Post-operative study was performed minimum 6 months after mitral valve replacement (mean after 8 months) and again after minimum 3 years (mean after 40 months). In most of assessed--22 patients (74%) airway obstruction was noticed, in 8 patients without obstruction nonspecific histamine provocation test was performed. Increased airway reactivity was found in 4 patients only, in another 4 patients (13%) there was no airway function disturbances. After mitral valve replacement significant improvement in all cardiac parameters including NYHA functional class was observed. No airway function improvement occurred. Only small tendency to improve airway function was noticed as far as it concerns VC, FEV1, MEF50, MEF75 iTGV with exclusion of Raw. Analysis after dividing study group into 3 subgroups with increasing airway function disturbances (from predicted to hyperreactivity and obstruction) was also performed. The improvement in airways function was noticed only in 6 patient (20% studied). In patients with mitral valve disease airway function disturbances as obstruction and bronchial hyperreactivity persist in long term follow-up after mitral valve replacement.     

Butterfly修复技术应用于二尖瓣后叶严重脱垂患者外科修复的中远期疗效分析

目的:探讨二尖瓣Butterfly修复技术应用于二尖瓣后叶严重脱垂患者外科修复的中远期疗效。方法:回顾性分析2016年7月—2019年10月南京大学医学院附属鼓楼医院34例行外科瓣膜修复的二尖瓣后叶严重脱垂患者的临床资料。其中男21例、女13例,年龄33～73岁。患者均在浅低温体外循环下完成二尖瓣Butterfly修复...     

The case of an explanted 16-year-old mitral Carpentier-Edwards pericardial bioprosthesis

We report the case of a mitral Carpentier-Edwards pericardial bioprosthesis that was explanted from a 43-year-old female patient because of structural valve deterioration 16 years following implantation. Upon removal, the prosthesis was found to be discolored and all leaflets were stiff and hard, showing extensive calcification, pannus overgrowth, leaflet hematoma, and multiple disruptions. One leaflet presented a wavy free margin due to commissural disruptions, leading to incomplete cusp coaptation. The accumulated physical symptoms of the patient were consistent with these findings.     

Late prosthetic valve endocarditis due to Cardiobacterium hominis, an unusual complication

We report a case of prosthetic valve endocarditis caused by Cardiobacterium hominis in a patient who had undergone atrial septal defect closure and mitral valve replacement of the heart in 1978. He presented with pyrexia of unknown origin and congestive cardiac failure. Investigations revealed infective endocarditis of prosthetic valve in mitral portion. Blood culture samples grew C. hominis. The patient was empirically started on vancomycin and gentamicin intravenously and ceftriaxone was added after isolation of the organism. Though subsequent blood cultures were negative, patient remained in congestive cardiac failure and died due to complications.     

个体化治疗预防小主动脉瓣环瓣膜置换后瓣膜与患者的不匹配

背景：小主动脉瓣环主动脉瓣置换是心外科手术的难点,治疗不当可能出现瓣膜与患者不匹配现象,使左室流出道狭窄、跨瓣压差增大,引起左室后负荷增加致心肌肥厚甚至充血性心力衰竭。 目的：总结预防小主动脉瓣环瓣膜置换后发生人工心脏瓣膜与患者不匹配的治疗策略。 方法：小主动脉瓣环均主动脉瓣置换患者85例。瓣口直径>17 mm,≤19 mm的患者,选19 mm SJM Regent 瓣;对瓣口直径≤17 mm的患者,用牛心包补片加宽瓣环,再选19 mm SJM Regent 瓣行瓣膜置换;对于瓣口直径>19 mm,≤21 mm,选21 mm Hancock II ultra生物瓣置换。治疗后应用超声心动图测量有效瓣口面积指数、左心室重量指数、室间隔厚度、左心室后壁厚度、跨瓣峰速、跨瓣压差和跨瓣平均压。出院后通过门诊对患者进行随访,定期复查超声心动图。 结果与结论：治疗后早期无死亡病例,均治愈出院。随访时间为6个月-3年。主要并发症为低心排综合征2例、二次开胸止血1例、呼吸机依赖2例。所以患者均未出现脑栓塞或脑出血等脑部并发症。无瓣膜功能失调或卡瓣。未发现牛心包补片撕裂、瘤样膨出、钙化、血栓形成、免疫反应和感染等情况。81例获随访,随访率为 95%(81/85)。NYHA心功能分级Ⅰ级65例,Ⅱ级16例。各不同瓣环直径患者治疗后跨主动脉瓣峰速和平均压差均明显降低,有效瓣口面积指数明显增加,左心室重量指数、室间隔厚度和左心室后壁厚度均明显降低,均未出现人工心脏瓣膜与患者不匹配。置换21 mm Hancock II ultra 生物瓣和21 mm SJM Regent 瓣组间的比较,前者获得了更好的跨瓣峰速和平均压差,以及更好的左心室重塑指标。19 mm Regent 瓣患者治疗后体质量和体表面积较治疗前明显增加。结果提示对于小主动脉瓣环的患者应采取个体化的治疗策略预防主动脉瓣置换后瓣膜与患者不匹配的发生。 中国组织工程研究杂志出版内容重点：肾移植;肝移植;移植;心脏移植;组织移植;皮肤移植;皮瓣移植;血管移植;器官移植;组织工程全文链接：     

Prevalence of pannus formation after aortic valve replacement: clinical aspects and surgical management

Pannus formation after aortic valve replacement is not common, but obstruction due to chronic pannus is one of the most serious complications of valve replacement. The causes of pannus formation are still unknown and effective preventive methods have not been fully elucidated. We reviewed our clinical experience of all patients who underwent reoperation for prosthetic aortic valve obstruction due to pannus formation between 1973 and 2004. We compared the initial 18-year period of surgery, when the Björk–Shiley tilting-disk valve was used, and the subsequent 13-year period of surgery, when the St. Jude Medical valve was used. Seven of a total of 390 patients (1.8%) required reoperation for prosthetic aortic valve obstruction due to pannus formation. All seven patients were women; four patients underwent resection of the pannus and three patients needed replacement of the valve. The frequency of pannus formation in the early group was 2.4% (6/253), whereas it was 0.73% (1/137) in the late group (P < 0.05). Pannus was localized at the minor orifice of the Björk–Shiley valve in the early group and turbulent transvalvular blood flow was considered to be one of the important factors triggering its growth. We also consider that small bileaflet valves have the possibility of promoting pannus formation and that the implantation of a larger prosthesis can contribute to reducing the occurrence of pannus.     

Patient–prosthesis mismatch may be irrelevant after aortic valve replacement with the 19-mm Perimount pericardial bioprosthesis in patients aged 65 years or older

The prevalence of patient–prosthesis mismatch (PPM) and its influence on clinical midterm results were examined in elderly patients whose activity was supposed to be less than that of younger patients. We evaluated valve function and the effects of PPM on the midterm results of the 19-mm Carpentier–Edwards Perimount (CEP) pericardial aortic valve in patients aged 65 years or older. Between August 1996 and May 2005, 51 patients underwent aortic valve replacement with the 19-mm CEP valve. The mean follow-up was 2.4 ± 1.8 years, involving a total of 134.4 patient-years. The mean age and body surface area at operation were 74.0 ± 5.0 years and 1.41 ± 0.14 m². There were two (3.9%) operative deaths. Three patients (5.9%) underwent enlargement of their small aortic annuli. The actuarial survival rate at 8 years, including operative mortality, averaged 90.2% ± 4.7%. The freedom from thromboembolism, reoperation, and valve-related mortality averaged 75.0% ± 21.7%, 97.8% ± 2.2%, and 95.3% ± 3.2%, respectively, at 8 years. High preoperative peak and mean transvalvular pressure gradients were significantly improved after the operation (peak, 93 ± 35 versus 28 ± 12 mmHg; mean, 58 ± 19 versus 17 ± 7 mmHg, respectively; P < 0.01). The mean left ventricular mass index was reduced from 192 ± 44 to 142 ± 46 g/m² at late follow-up (P < 0.01). The prevalence of PPM was low (17.6%) when an indexed effective orifice area of less than 0.85 cm²/m² was taken as the definition of PPM. The clinical results, postoperative pressure gradients, and reduction in left ventricular mass index were not different between the PPM and no-PPM groups. The 19-mm CEP valve produced satisfactory midterm clinical outcomes in patients aged 65 years or older whose activity was supposed to be less than that of younger patients, regardless of the presence or absence of PPM. Moderate PPM was rare and it did not adversely impact on the midterm results. The application of annulus enlargement could be limited to the small number of patients for whom the 19-mm CEP valves are not able to be inserted.     

Influence of pressure load on durability of pulmonic xenobioprostheses in young adults

The aim of this study was to investigate the effects of pressure load (pulmonary arterial pressure) on the long-term durability of second-generation xenobioprostheses in the pulmonary position in young adults. Thirteen patients survived pulmonary valve replacement for pulmonary regurgitation using the second-generation aortic porcine bioprosthesis at Sapporo Medical University School of Medicine between 1985 and 2009. The mean age at pulmonary valve replacement was 40.5 years, and the mean prosthetic valve size was 25.3 mm. Two patients developed structural valve deterioration 6 and 9 years, respectively, after pulmonary valve replacement. Both prosthetic valves with structural valve deterioration were subjected to long-term high levels of pressure load. No valve structural failure was observed in the remaining 11 patients who experience low-pressure load during a mean follow-up period of 11.9 years. The freedom from structural valve deterioration at 15 years was 75.8% for the overall population, but 100% for those with low-pressure load. Our findings suggest that the long-term durability of pulmonary-site bioprosthetic valves in young adult patients is promising but that pressure load might be a risk of the limited durability of the valve.     

Structural valvular deterioration of Hancock standard valve in the mitral position 33 years after initial implantation

A 77-year-old woman who had undergone mitral valve replacement (MVR) with a 29 mm Hancock standard (H–S) bioprosthesis (Model 242) and tricuspid annuloplasty (Kay’s method) at the age of 44 years was admitted urgently with acute heart failure. Echocardiography showed severe transvalvular leakage of the prosthesis and moderate tricuspid regurgitation. The patient underwent reMVR with a 29 mm Carpentier-Edwards Perimount Magna Mitral bioprosthesis and tricuspid annuloplasty with a 30 mm MC3 ring. The explanted bioprosthesis showed mild calcification and a tear in the leaflet, dehisced commissures and pannus overgrowth. To our knowledge there are no reports describing H–S valves that were still functioning over 30 years after implantation. Herein, we report a case of reMVR in a patient with an H–S valve that had been implanted 33 years previously.     

右胸骨旁微创小切口体外循环停跳下二尖瓣置换术20例

目的 探讨右胸骨旁微创小切口体外循环停跳下二尖瓣置换术治疗二尖瓣病变的可行性,评价其临床应用价值。方法 回顾性分析2016年9月—2017年5月蚌埠医学院第一附属医院心脏外科采用右胸骨旁微创小切口体外循环停跳下行二尖瓣置换术20例患者的临床资料,其中男6例、女14例,年龄39~72(55±3.8)岁。均通过右胸骨旁第四肋间6~10 cm横切口进胸,股动脉插管、右房房腔管引流建立体外循环,经胸直视下阻断升主动脉,心脏停跳后经左房入路行二尖瓣置换。结果 无围术期死亡,体外循环时间118～205(150.3±37.2)min,主动脉阻断时间98～189(133.5±27.4)min,术后机械通气时间(11.1±10.4)h,ICU停留时间(1.3±0.5)d,住院时间(7.3±1.7)d。患者术后平均随访(2.1±1.7)月,瓣膜位置均良好、启闭功能正常,无瓣周漏发生及严重心脑血管并发症出现。结论 作为向全胸腔镜下二尖瓣置换过渡的一种微创术式,右胸骨旁微创小切口体外循环停跳下二尖瓣置换术安全、可靠,早期临床效果确切。     

A primary cardiac sarcoma preoperatively presented as a benign left atrial myxoma

Primary cardiac sarcomas are extremely rare. We report a case of a primary cardiac sarcoma with myxoid change, which originally presented as a benign cardiac myxoma on a two- dimensional echocardiogram. On operating, the mass was found to extend into the posterior left atrial wall, the left pulmonary vein, and the mitral valve. The patient underwent wide resection of the left atrium, a mitral valve replacement and a left pneumonectomy. The histological diagnosis was of an undifferentiated primary cardiac sarcoma. The patient had postoperative chemotherapy. The patient expired 11 months after surgery due to a recurrence of the cardiac sarcoma. Although most tumors that develop in the left atrium are benign myxomas, we should make a preoperative differential diagnosis.     

Sphincters of the pulmonary veins in man,and their significance

Summary Pressure curves in the pulmonary vein and in the left auricle were recorded in patients with stenosis of the left atrioventricular valve before and after mitral valvotomy. The curves showed that the sphincters of the pulmonary veins may fail when the mean pressure in the left auricle exceeds 20 mm Hg. Normally, by blocking the reverse flow, the sphincters protect the pulmonary vessels from the back pressure wave. With increased pressure in the left auricle, insufficiency of the pulmonary vein sphincters could provoke changes in the small pulmonary vessels, which were demonstrated histologically on biopsy material, and which had the effect of increasing the resistance to blood flow. Auricular fibrillation, by causing the sphincters to become ineffectual even when the hypertension in the left auricle is moderate, may promote a relatively early rise of pulmonary vascular resistance.(Presented by Active Member AMN SSSR V. V. Parin) Translated from Byulleten' Éksperimental'noi Bioligii i Meditsiny, Vol. 51, No. 6, pp. 14–17, June, 1961     

Increased risk for double valve replacement with tissue and mechanical prostheses

We wanted to determine whether there is any advantage of using a mitral tissue valve, when aortic and mitral valves are simultaneously replaced. We placed a tissue valve in the mitral position and a mechanical valve in the aortic position in 22 cases (combined group). In 31 other double valve replacements, mechanical prostheses were chosen for both positions (mechanical group). The mean follow-up time for the combined group was 8.9 years, and that for the mechanical group was 7.2 years. The 10-year survival rate and freedom from thromboembolism at 10 years were not different in the two groups. Treatment-related hemorrhage was seen in 3 patients of the combined group alone. Five patients among the combined group underwent reoperation because of bioprosthetic dysfunction, and the rate of freedom from reoperation at 10 years was 75 ±12%. The rate of freedom from all complications at 10 years was 43±11% for the combined group and 70±8% for the mechanical group. We find no advantage in mixing aortic mechanical and mitral tissue valves when performing double valve replacement.