Tricuspid valve replacement with the St. Jude Medical valve

A study was conducted on 20 patients who underwent tricuspid valve replacement (TVR) with the St. Jude Medical (SJM) valve. Isolated TVR was performed on 9 patients, and additional mitral, or mitral and aortic valve replacements were performed on 11 patients. Four patients (20%) died in the early postoperative period, but there were no deaths related to the SJM valve in the tricuspid position. The mean follow-up period of the 16 survivors was 74.4 months, and there have been no deaths during the follow-up period. The postoperative actuarial survival rate was 80%, 10 years after surgery. Three patients, representing 0.25%/patient-months, developed valve thrombosis, the valve thrombosis-free rate being 72.8%, 10 years after surgery, while entrapment of a leaflet by endothelial pannus was found in one patient, representing 0.08%/patient-months. Thus, the incidence of all prosthetic valve-related complications was 0.34%/patient-months, and the postoperative complication-free rate was 65.3%, 10 years after surgery. The medium-term follow-up study of TVR with the SJM valve revealed no prosthetic valve-related deaths and a relatively low incidence of prosthetic valve-related complications. However, as with other mechanical valves, valve thrombosis was a major risk posed by the SJM valve in the tricuspid position.     

Intermittent opening of a mechanical mitral valve prosthesis due to pannus formation; report of a case

A 76-year-old woman with a history of severe mitral valve stenosis had undergone mitral valve replacement with a 27 mm St. Jude Medical (SJM) valve in 1991. Follow-up transthoracic echocardiography revealed an increase in the pressure gradient across the mitral prosthesis 16 years after the surgery. Prosthetic valve dysfunction was suspected, but transesophageal echocardiography and cineradiography failed to show mechanical valve dysfunction. Two years later, she presented with dyspnea on exertion and leg edema. Cineradiography revealed intermittent restriction of the opening of the mechanical valve leaflet approximately every 10 beats. Thus, we diagnosed intermittent prosthetic valve dysfunction and performed a reoperation. On inspection of the prosthesis, we observed semicircular pannus formation around the posterior leaflet in the ventricular side. It was considered that the pannus tissue had interfered with 1 leaflet opening of the mitral valve prosthesis, resulting in intermittent valve dysfunction. We replaced the prosthesis with a new 25 mm SJM valve. The patient was discharged after confirmation of normal prosthetic function.     

Case report of a malfunctioning SJM 19 A aortic valve prosthesis requiring reoperation

The patient was a 56-year-old female diagnosed with poor lung function who had undergone an aortic valve replacement 10 years ago, receiving an SJM 19 A prosthetic valve. She suffered from dyspnea and chest pain with postural change. Her anticoagulation level was maintained therapeutic. A cinefluoroscopy showed that one of the leaflets in the prosthetic valve was not moving. The aortic peak pressure gradient was calculated to be 68 mmHg using Doppler echocardiography. The patient's clinical condition improved after thrombolytic therapy with urokinase, but a complete normalization of her prosthetic discs was not obtained, so the patient was treated surgically. After an aortotomy, a pannus formation covering the entire SJM 19 A valve was observed. The aortic annulus was estimated to be 16 mm in diameter after the excision of the SJM 19 A valve and required before a larger prosthesis could be inserted. A SJM 19 HP valve was then anchored to the enlarged annulus. Her postoperative course was uneventful. We report a case requiring reoperation after a small aortic mechanical valve prosthesis implanted 10 years previously was damaged by thrombosis and pannus. Pannus formation on small aortic prosthesis easily caused hemodynamic obstructions and mechanical failure. Intensive evaluation with Doppler echocardiography and cinefluoroscopy is required for such patients.     

Obstruction of St Jude medical valves in the aortic position: a consideration for pathogenic mechanism of prosthetic valve obstruction

Between 1995 and 2000, 8 patients with St. Jude Medical (SJM) valves in the aortic position required 9 redo valve replacement for prosthetic valve obstruction. Obstruction of the prosthetic valve was diagnosed by simultaneous echocardiography and cineradiography, and process of restricted leaflet movement that progressed to hemodynamic impairment was observed by serial studies in three recent patients. An oral anticoagulation was considered to be adequate in all patients except one patient who had withdrawal of warfrain. Pannus was the sole cause of valve obstruction in seven events in 6 patients, and both thrombus and pannus in 2 patients. Pannus overgrowth was found on the inflow aspect of the SJM valve, and involved the ends of the straight edge of the leaflets over pivot guards. These results suggest that pannus might play the primary role in development of obstruction of aortic SJM valves in patients on adequate oral anticoagulation.     

Selection of a prosthetic valve for mitral valve replacement

The early and the late results of mitral valve replacement were retrospectively evaluated to delineate the concept of selection of the prosthetic valve for the mitral position. The mitral valve was replaced with porcine bioprosthesis (P-B) in 102 patients and with St. Jude Medical prosthesis (SJM) in 341 patients between 1975 and 1987. Operative mortality was 5.3% for the SJM and 8.8% for the P-B group (N.S.). Cumulative duration of follow up was 1479.8 patient-years for the SJM and 888.9 patient-years for the P-B group. Actuarial survival rate was 90% for the SJM at 9 years and 81%, 76% for the P-B group at 10 and 13 years (N.S.). Freedom from valve-related death was 94% for the SJM at 9 years and 94% for the P-B at 13 years (N.S.). Thrombo-embolic complications occurred at an incidence of 0.47%/patient-years (p-y) for the SJM and 0.67%/p-y for the P-B group (N.S.). Freedom from prosthetic valve dysfunction due to primary tissue failure (PTE) lowered rapidly after the seventh postoperative year from 88% to 35% in the P-B group. Prosthetic valve dysfunction free rate was significantly lower in the P-B group compared with the SJM between the seventh post operative year and ninth postoperative year (p less than 0.01). From this analysis, we believe that the SJM prosthesis is suitable cardiac valve prosthesis to the mitral position.     

Operative results of tricuspid valve replacement with St. Jude Medical prosthesis

Since 1974, 14 patients underwent tricuspid valve replacement (TVR) with prosthetic heart valves. Hardy's operation was undergone in 2 patients with Ebstein's anomaly and mitral valve surgery or multiple valve surgery were undergone in 9 patients with rheumatic valvular disease, concomitantly. Four types of prosthetic heart valves were used in the tricuspid position, i.e. 2 Starr-Edwards prostheses, 1 Hancock xenograft, 1 Bj?rk-Shiley prosthesis and 12 st. Jude Medical prostheses. The operative mortality rate was 14.3% (2/14) and 2 hospital deaths were due to low cardiac output syndrome. Twelve survivors have been followed with a maximum follow-up of 13 years and the mean of 4.7 years. There were 3 late deaths due to congestive heart failure and prosthetic valve endocarditis (PVE) of the aortic Bj?rk-Shiley prosthesis. There was 1 PVE of the tricuspid Starr-Edwards prosthesis and 1 thrombosis of the tricuspid Bj?rk-Shiley prosthesis, but no thrombosis and no other valve-related complications of SJM prostheses in the tricuspid position. The post-operative NYHA function class improved satisfactorily in 9 survivors. Judging from our relatively satisfactory post-operative results in TVR cases using SJM prostheses, SJM prosthesis in the tricuspid position is one of advisable prosthesis to get satisfactory hemodynamic improvement post-operatively.     

Unexpected mechanical bileaflet valve thrombosis in mitral position: what is better to do, re-replacement or thrombolysis

BACKGROUND AND AIMS: The longevity of the mechanical heart valve prosthesis is an advantage when compared with its biological counterpart, although the former carries a risk of thrombosis depending on valve design, materials and host-related interface; therefore, a patient with a mechanical valve prosthesis, particularly in mitral position, is at risk for systemic thromboembolism even when properly anticoagulated. PATIENTS AND METHODS: We report a case of a 60-year-old woman who underwent a mitral valve replacement with a St. Jude Medical (SJM) standard bileaflet mechanical heart valve. RESULTS: On the twelfth post-operative day a primary thrombosis with blockage of the anterior valve leaflet occurred. CONCLUSIONS: Aware of the risk of recurrent thromboembolism in this special clinical framework and possible cerebral bleeding in case of thrombolysis, we replaced the prosthesis with a new biologic porcine valve, the SJM Biocor.     

Prosthetic valve thrombosis: twenty-year experience at the Montreal Heart Institute

BACKGROUND: Prosthetic valve thrombosis is a life-threatening complication. We reviewed the incidence, risk factors, and treatment strategies of this rare complication. METHODS: From February 1981 through January 2001, 5430 valve operations were performed in 4924 patients at the Montreal Heart Institute. Of this cohort, 39 patients presented with prosthetic valve thrombosis and had complete follow-up data obtained from our prospective valve clinic database. RESULTS: In this series 82% of patients were women, and the mean age was 58 +/- 11 years. The underlying pathology involved the mitral valve in 75% of cases. Most prosthetic valve thromboses occurred with mechanical prostheses (95%). The time interval from first valve replacement to prosthetic valve thrombosis was 39 +/- 42 months. The most frequent clinical presentation was severe congestive heart failure (44%). On prosthetic valve thrombosis presentation, the international normalized ratio was less than 2.5 in 54%, with inadequate anticoagulation management in 26% and poor compliance in 26%. Eighty-two percent of patients underwent a surgical procedure, consisting of thrombectomy in 47%, mitral valve replacement in 47%, and aortic valve replacement in 6% of patients. The 30-day operative mortality and total in-hospital mortality after prosthetic valve thrombosis were 25% and 41%, respectively. The 10-year actuarial survival after prosthetic valve thrombosis was 46% +/- 10%. CONCLUSION: Inadequate level of anticoagulation is the most important factor involved in the pathogenesis of prosthetic valve thrombosis. The overall mortality rate despite surgical treatment remains high. This study underscores the importance of meticulous surveillance of anticoagulation therapy in patients with prosthetic valves.     

Severe stenosis of bioprosthetic valve due to late valve thrombosis

The typical cause of bioprosthetic valve dysfunction over years is calcification of leaflets, pannus formation, or tears due to structural degeneration. Thrombosis is rare as the valves get endothelialized early on, and, hence, anticoagulation is not recommended beyond 6 months after valve replacement. While bioprosthetic valve thrombosis is unusual (0.03% to 0.34%/year), it can be associated with significant mortality and morbidity. Here, we present a case of a middle-aged man with history of bioprosthetic mitral valve who presented with syncopal episode and was referred to us for mitral valve replacement for tentative bioprosthetic valve degeneration and stenosis. However, preoperative work up revealed prosthetic valve thrombosis which was successfully treated with anticoagulation.     

Acute mechanical valve thrombosis of the St. Jude medical prosthesis

From 1986 to 1996, 2585 patients underwent valve replacement with the St. Jude medical prosthesis. Sixty experienced mechanical valve thrombosis. Seventeen of 60 patients (28.3%) had isolated aortic valve replacements, 33 had isolated mitral valve replacements (55%), and 10 had double valve replacements (16.7%) (aortic and mitral valve replacement). All patients who underwent reoperation for mechanical valve thrombosis were functional Class III or IV. Against medical advice, systemic anticoagulation with warfarin sodium had been discontinued or used only intermittently. Thus, anticoagulant activity was not adequate. The diagnosis of thrombosis was made by clinical examination, laboratory findings, and echocardiography and cineradiography. Of the 60 patients, 9 patients died early after surgery or before discharge. Most of the deaths were attributed to low cardiac output. The overall hospital mortality was 15%. The overall 10-year actuarial survival rate was 82.8+/-1.6%. In our study, reoperation for thrombosed mechanical prosthesis was not an independent parameter determining mortality. Age was the only statistically important hospital mortality predictor. Of this group, 90% suffered mechanical valve obstruction within the first 5 years after operation. These results suggest that valve re-replacement appears to be a suitable surgical treatment for thrombosis of mechanical prosthetic valves, especially in the young. In these patients subsequent anticoagulation management is necessary.     

St. Jude prosthetic valve obstruction in the mitral position

We report a surgical case of prosthetic valve obstruction after mitral valve replacement by a St. Jude Medical valve. A 66-year-old woman was admitted because of congestive heart failure. Prosthetic valve obstruction was diagnosed by transthoracic echocardiography and cine-fluoroscopy. Re-do cardiac surgery was indicated after a week of heparinization. Circumferential pannus formation into the orifice beyond the pivot guard of the prosthesis on the atrial side and one piece of the leaflet was covered with a fibrous overgrowth on the atrial side. We concluded that once the diagnosis of valve thrombosis is established, urgent operation is preferred in patients with hemodynamic instability before the development of cardiogenic shock or multiple organ failure.     

Thrombosis of two St. Jude Medical prostheses in one patient after triple valve replacement. Case report and review of the literature

Reports of experience with the St. Jude Medical (SJM) valve state that thrombosis of the prosthesis is a rare complication. In a 57-year-old woman, reoperation was necessary 12 months after triple valve replacement using SJM prostheses because of thrombosis of the valves in the tricuspid and aortic positions. Dysfunction of both mechanical valves was detected clinically by changing heart sounds and the appearance of murmurs. Echocardiography and cinefluoroscopy confirmed at least one fixed leaflet of the tricuspid prosthesis, but abnormalities of the aortic prosthesis could not be detected. At reoperation, the SJM prosthesis in the tricuspid position was almost completely thrombosed and was replaced by an Ionescu-Shiley bioprosthesis. A thrombotic formation at the hinge point of the SJM aortic prosthesis was removed. To our knowledge, this is the first report of a thrombotic complication of two SJM prostheses after triple valve replacement in one patient.     

Clinical evaluation of ATS prosthetic valve by doppler echocardiography: comparison with St. Jude Medical (SJM) valve.

ATS valve is a bileaflet valve developed to have a superior function to traditional prosthetic valves on anti-thrombogenesis and hemolysis. The orifice area was enlarged in consequence of making its orifice with pyrolytic carbon materials, and the pivot was open pivot and the strut was eliminated. The efficiency of this valve has been reported in the Europe. In Japan, its clinical trial was performed in September 1993 and its clinical use was permitted in August 1996. In this study, we compared the functions of ATS and St. Jude Medical (SJM) valves with echocardiography. The pressure gradients at the mitral valve position were not significantly different between ATS and SJM valves, but that of ATS was lower than that of SJM. The pressure gradient at the aortic valve position of ATS was also lower than that of SJM, and especially those of the patients who performed aortic valve replacement with 23-mm ATS and SJM valves were 8.9+/-1.6 and 23.3+/-6.6 mmHg, showing a significant difference. Though further observation and review of this valve are needed at the chronic phase, ATS valve is an excellent bileaflet valve on the valvular function, showing a low pressure gradient.     

人工心脏瓣膜置换术后心内血栓形成危险因素的一年随访研究

目的 探讨人工心脏瓣膜置换术后心内血栓形成的危险因素.方法 回顾性分析2005年1月至2009年4月690例瓣膜置换手术者中在住院期间或1年内随访发现心内血栓形成的29例患者,其中男性11例,女性18例;年龄12～70岁,平均48岁.单因素和Logistic回归多因素分析影响瓣膜置换术后心内血栓形成的危险因素.结果 单因素分析显示,21个独立因素中共有7个因素即生物瓣置换、阿司匹林抗凝、二尖瓣置换、心房颤动、术前左心房内径、术后左心房内径、术后纤维蛋白原水平与术后心内血栓形成有关(P<0.05).多因素分析显示,二尖瓣置换(OR=9.815,P<0.05)、心房颤动(OR=5.267,P<0.05)、术前左心房增大(OR=4.529,P<0.05)是术后心内血栓形成的独立危险因素.结论 人工瓣膜置换术后心内血栓形成与二尖瓣置换、心房颤动、术前左心房增大有相关性.应重视生物瓣置换术后的抗凝.     

Valve thrombosis of St. Jude Medical prosthesis; report of three cases

Three cases with valve thrombosis of St. Jude Medical prosthesis (SJM valve) are reported. Incidence of valve thrombosis of SJM valve was 0.15%/patient-year. Cineradiography was useful to make the diagnosis. SJM valves were implanted with the hinges anatomically oriented in mitral position, and in both aortic and tricuspid positions with the leaflet opening parallel to the ventricular septum. Therefore, we recommend that SJM valve should be placed with the hinge antianatomically oriented in mitral position, and in both aortic and tricuspid positions with the leaflet opening to be perpendicular to the interventricular septum, respectively.     

Emergency pulmonary autograft mitral valve replacement in a child

Mitral valve replacement in small children imposes significant clinical difficulties because of the relatively small mechanical prosthetic valves required and the need for lifelong anticoagulation therapy. A child weighing 10.4 kg presented with thrombosis of her 19-mm mechanical mitral prosthesis 4 weeks after implantation despite appropriate oral anticoagulation therapy. An emergency mitral valve replacement with a pulmonary autograft was successfully performed with encouraging short-term results.     

A case of transient bioprosthetic valve regurgitation and hemolysis devoloping early after surgery using Carpentier-Edwards valve.

The Carpentier-Edwards pericardial bioprosthesis has been markedly improved in the long-term results and valve-related complications including valve dysfunction, compared to the previous generation bioprosthesis. We report a patient in whom transient prosthetic valve regurgitation and hemolysis occurred early after mitral valve replacement using a Carpentier-Edwards pericardial bioprosthesis and were resolved by preservative therapy. The patient was a 77-year-old female diagnosed with severe mitral valve stenosis and insufficiency. She underwent mitral valve replacement with a Carpentier-Edwards pericardial bioprosthesis. Opening and closing of the three leaflets looked good on intraoperative transesophageal echocardiography (TEE). The only prosthetic valve regurgitation was evident at the central region where the leaflets form coaptation, and no abnormal findings were seen. Serum lactate dehydrogenase (LDH) was decreased to 405 U/l after surgery. However, LDH again began to increase on the 3rd day after surgery and it increased to 1,830 U/l on the 14th day after surgery. Hemolytic urine was detected on 10th day after surgery. PVL was not detected, but moderate abnormal regurgitation from the outside of the stent pocket was detected on TEE. Revision of valve replacement was considered, but LDH thereafter to 393 U/l on 41st day after surgery. The TEE was repeated, and only a trace of central jet was detected without abnormal regurgitation, unlike the previous examination. The patient did not develop any complications thereafter and was discharged on 47th day after surgery. LDH was nearly normal at the time of discharge.     

Obstructive prosthetic atrioventricular valve thrombosis in a woman with congenitally corrected transposition of the great arteries during estrogen replacement therapy for pituitary dysfunction

A 27-year-old woman was admitted because of breathlessness, orthopnea, and hemoptysis. The present patient was diagnosed with congenitally corrected transposition of the great arteries (cc-TGA) and underwent systemic atrioventricular valve replacement for severe insufficiency at 23 years of age. She also had been treated with oral conjugated equine estrogen (Premarin) because of congenital pituitary dysfunction. Despite appropriate anticoagulation therapy with warfarin, echocardiography and fluoroscopy showed stuck leaflets of the prosthetic valve due to thrombosis. She underwent emergent surgical valve replacement. This rare association suggests that oral hormone replacement therapy poses a risk of thrombosis especially in patients with cc-TGA after prosthetic valve replacement.     

Prosthetic aortic valve dysfunction due to projection of the left ventricular outflow septum

Prosthetic valve dysfunction at the aortic position is generally caused by either pannus overgrowth or thrombus or both. We encountered a case with prosthetic valve dysfunction who had undergone an aortic valve replacement 4 years and 5 months before, receiving SJM-HP 21 mm. During the initial operation, a prosthetic valve was implanted parallel to the ventricular septum and slightly up toward the non-coronary sinus (Olin technique) because of a narrow aortic annulus. Before re-do surgery, Doppler echocardiography and cinefluoroscopy showed an incomplete opening of 1 leaflet of the prosthetic valve. At the re-do operation, it was observed that the movement of the anterior leaflet of the prosthetic valve was disturbed by the projecting ventricular septum. After the projecting ventricular septum was excised, SJM-regent 17 mm valve was implanted perpendicular to the septum at the supra-annular position. Postoperative course was uneventful. The postoperative aortic peak pressure gradient decreased to 25 mmHg by Doppler echocardiography.     

Thrombosed Bj?rk-Shiley standard disc mitral valve prosthesis

Between April 1980 and June 1986, 274 patients underwent mitral valve replacement (MVR) with the Bj?rk-Shiley (BS) standard disc mitral valve prosthesis at the American University of Beirut Medical Center (AUBMC). Eleven patients (3.9%) presented 6-41 months after surgery with prosthetic valve dysfunction due to thrombosis. Inadequate control of anticoagulation was the major factor predisposing to thrombosis in all except one. All patients had documented rheumatic valvular disease. Nine patients were operated on an emergency basis and two died before any surgical intervention was possible. Thrombectomy was performed on six patients with four survivors and MVR in three with two survivors. Two patients died intraoperatively (22%). Three pregnant patients underwent mechanical declotting; pregnancy was terminated by abortion in 2 and by caesarean section and live birth in one. We conclude that implantation of the BS mitral valve prosthesis mandates emphasis on anticoagulation and the difficulty encountered with continuous anticoagulant therapy in pregnancy.