Triple-valve treatment for prosthetic valve endocarditis occurring 20 years after implantation of a Carpentier-Edwards pericardial bioprosthesis in the aortic valve

A 68-year-old woman had undergone aortic valve replacement and open commissurotomy 20 years previously. At the beginning of 2008, fever, cold, and heart failure symptoms were noted. On blood culture, Streptococcus oralis was detected three times. Surgery was performed under a diagnoses of prosthetic valve endocarditis in the aortic valve, mitral stenosis and insufficiency, and tricuspid insufficiency. Techniques consisted of additional aortic valve replacement, mitral valve replacement, and tricuspid annuloplasty. Vegetation was macroscopically and pathologically observed in the extirpated Carpentier-Edwards pericardial bioprosthesis that had been placed in the aortic valve. There was no postoperative recurrent inflammatory response. The patient was discharged 32 days after surgery.     

Mechanical valve thrombosis in the tricuspid position--reoperative management of 2 cases

Because valve thrombosis occurred after the tricuspid valve replacement with the mechanical valve, we performed replacement of the mechanical valve with the bovine pericardial valve in two cases. Case 1: The patient, at 13 years old, received open-heart surgery to correct infundibular stenosis. At 23 years of age, decortication and tricuspid valve replacement (TVR) with a phi 31 mm Bj?rk-Shiley valve were performed due to constrictive pericarditis and tricuspid regurgitation developed after the initial operation. Thrombosis of the mechanical valve occurred after the TVR. Treatment with urokinase for the thrombolytic therapy failed to improve the valve opening. Finally 12 years after the TVR, replacement of the mechanical valve with a phi 27 mm Carpentier-Edwards bovine pericardial valve was performed. Case 2: The patient, at 21 years old, received open-heart surgery to close an atrial septal defect. At 40 years of age, mitral and tricuspid valve replacements were performed because regurgitation developed in both valves. The mitral and tricuspid valves were replaced with phi 27 mm and 31 mm St. Jude Medical valves, respectively. Thrombosis of the mechanical valve used for the TVR occurred 2 months after the replacement. The mechanical valve was replaced with a phi 27 mm Carpentier-Edwards bovine pericardial valve. In both cases, subjective symptoms improved and prosthetic valve complications did not occur after re-replacement with the bovine pericardial valve. These cases suggested that for TVR a bovine pericardial valve of sufficient size would be better to select than a mechanical valve.     

Secondary mitral valve replacement in antiphospholipid syndrome and chronic renal failure

A 48-year-old woman admitted with progressive dyspnea had previously been diagnosed with systemic lupus erythematosus, antiphospholipid syndrome, and chronic renal failure, and had undergone mitral valve replacement with a Carpentier-Edwards pericardial bioprosthesis for mitral insufficiency 9 years before. She suffered a cerebral infarction 5 years earlier, despite appropriate anticoagulant therapy. On admission, echocardiography showed severe bioprosthetic stenosis. Repeat mitral valve replacement was conducted using a Mosaic bioprosthesis. On postoperative day 2, when heparinization was commenced, she suddenly had an epileptic fit. She also developed ischemic necrosis of the fingers and toes, considered secondary to microthrombosis. Aspirin was administered and heparin replaced by warfarin sodium. Necrosis gradually disappeared, and she was discharged 3 months after surgery. The original bioprosthesis showed degenerative changes with significant thrombus formation on cusps, thought to be mainly due to her hypercoagulable state. Considering the thrombophilic tendency in patients with antiphospholipid syndrome, strict management of anticoagulant therapy is required.     

Re-operation of an aortic pericardial bioprosthesis 23-years after implantation; report of a case

A 49-year-old female suffered from dyspnea on exertion and jaundice from June, 2009. She had undergone aortic valve replacement with Carpentier-Edwards pericardial bioprosthesis due to active infectious endocarditis 23-years previously. The echocardiography showed severe aortic stenosis with moderate regurgitation. She was diagnosed as having prosthetic valve malfunction. Re-replacement of the aortic valve with mechanical valve was successfully performed. As far as we can see, this is one of the longest-term cases of implantation of pericardial bioprosthesis.     

Persistent cardiac failure after mitral valve replacement due to free-floating intracardiac thrombus formation

A case of free-floating left atrial-ventricular thrombus early after mitral valve replacement (Carpentier-Edwards pericardial bioprosthesis) is presented. Successful surgical removal was performed. The diagnostic and therapeutic efforts are discussed.     

Mitral valve repair with anterior leaflet augmentation for rheumatic mitral valve disease

A 74-year-old male with congestive heart failure was referred to our hospital, and massive mitral regurgitation as well as aortic stenosis and regurgitation were detected by echocardiography. His mitral valve was successfully repaired with anterior leaflet augmentation with the equine pericardial patch followed by aortic valve replacement. Postoperative transthoracic Doppler echocardiography revealed no mitral regurgitation. The patient recovered uneventfully and was discharged on the 19th postoperative day. At 2 years and 2nd month after the operation, he is well without limitation of daily activities and any evidence of mitral regurgitation.     

Use of the pericardial cord as a substitute for an infected mitral prosthetic ring associated with aortic prosthetic valve endocarditis

We report the case of a 61-year-old man with prosthetic valve endocarditis after both aortic valve replacement and mitral annuloplasty. Necrotic tissue and dehiscence of the suture line in the aortic annulus were found, and the infection extended to the anterior portion of the mitral prosthetic ring. The autologous pericardial cord was used as a substitute for the infected mitral prosthetic ring, and aortic root replacement was performed with a stentless bioprosthesis. The autologous pericardial cord was useful as a substitute for an infected mitral prosthetic ring.     

Early bioprosthesis failure in mitral valve replacement

The causes of early bioprosthesis failure include infective endocarditis, pannus formation, and structural valve deterioration. We reported a patient who suffered from early mitral bioprosthesis failure due to leaflets restricted by the subvalvular apparatus and early pannus formation. In patients with symptoms relapse and mitral regurgitation recurrence early after mitral valve replacement, early pannus formation needs to be anticipated, and surgical intervention should be performed if symptoms persist after medical treatment.     

Quadricuspid aortic valve associated with aortic stenosis and regurgitation

A 75-year-old man with moderate aortic stenosis and regurgitation admitted due to heart failure underwent uneventful aortic valve replacement with a Carpentier-Edwards pericardial bioprosthesis valve. A quadricuspid aortic valve discovered incidentally during surgery consisted of 4 of different sizes and a supernumerary cusp between the right and noncoronary cusps. No coronary abnormality was involved. Resected cusps showed fibrotic thickening with calcification and no sign of previous inflammatory disease. Although quadricuspid aortic valve is a very rare anomaly, its potential for severe valve failure in adulthood should not be neglected.     

Re-do mitral valve replacement using the valve-on-valve technique: a case report.

We report a repeated mitral valve replacement (re-do MVR) using the valve-on-valve technique for a degenerated bioprosthesis. A 49-year-old female, who had had a 29 mm Carpentier-Edwards mitral bioprosthesis for mitral regurgitation 20 years previously, was referred to our institution for dyspnea. She presented with pulmonary edema secondary to severe mitral bioprosthetic valve regurgitation. We replaced the degenerated mitral bioprosthesis with a 25 mm mechanical prosthesis using the valve-on-valve technique, as the struts of the bioprosthesis were embedded in the left ventricular myocardium. Removal of the bioprosthesis may be not only time-consuming but also complicated by cardiac rupture at the atrioventricular junction or the posterior left ventricular wall. The valve-on-valve technique is a simplified procedure that can avoid the potential complications of complete excision of the bioprosthesis. We believe this technique can be a useful strategy for patients with a degenerated mitral bioprosthesis.     

A case of thrombosed St. Jude Medical valve 16 years after initial mitral valve replacement]

We report successful surgery for a thrombosed St. Jude Medical (SJM) valve 16 years after the initial mitral valve replacement even under conditions of satisfactory anticoagulation therapy. A 61-year-old-female had intermittent claudication and was admitted to our hospital for examination. The prosthetic valve sounds were normal to auscultation and the left ankle-pressure index was decreased to 0.6. Transthoracic echocardiography revealed no mitral regurgitation and a mean mitral valve gradient of 6-7 mmHg. Furthermore, transesophageal echocardiography revealed that one of the leaflets of the prosthetic valve was entirely immobilized at the closing position and a mobile soft tissue mass, 5 mm in diameter, was detected at the atrial side of the obstructed leaflet. Although 96,0000 IU of urokinase was administered intravenously for a week, we could not confirm any change in leaflet mobility. At the time of surgery, the posterior leaflet of the SJM valve, which was implanted at an anatomical orientation, was obstructed at the closing position with old and fresh thrombi. We decided upon replacement with a CarboMedics 29 M prosthetic valve. Postoperative medication consisted of warfarin plus low-dose aspirin. Generally, valve thrombosis occurs within 5 years after valve replacement. However, valve thrombosis is possible even in a reliable SJM valve and as long as 16 years after replacement. Therefore, the implantation of an SJM valve at an anti-anatomical orientation might lower the incidence of valve thrombosis in addition to life-long anticoagulation therapy.     

Structural valve deterioration in mitral replacement surgery: comparison of Carpentier-Edwards supra-annular porcine and perimount pericardial bioprostheses.

BACKGROUND: Bioprostheses preserved with glutaraldehyde, both porcine and pericardial, have been available as second-generation prostheses for valve replacement surgery. The performance with regard to structural valve deterioration with the Carpentier-Edwards supra-annular (CE-SAV) porcine bioprosthesis and the Carpentier-Edwards Perimount (CE-P) pericardial bioprosthesis (Baxter Healthcare Corp, Edwards Division, Santa Ana, Calif) was evaluated to determine whether there was a difference in mitral valve replacement. METHODS: The CE-SAV bioprosthesis was implanted in 1266 overall mitral valve replacements (isolated mitral, 1066; mitral in multiple, 200) and the CE-P bioprosthesis in 429 overall mitral valve replacements (isolated mitral, 328; mitral in multiple, 101). The mean age of the CE-SAV population was 64.2 +/- 12.2 years and that of the CE-P population, 60.7 +/- 11.7 years (P =.0001). For the study, structural valve deterioration was diagnosed at reoperation for explantation. RESULTS: The freedom from structural valve deterioration was evaluated to 10 years, and the freedom rates reported are at 10 years. For the overall mitral valve replacement groups, the actuarial freedom from deterioration was significant (P =.0001): CE-P > CE-SAV for 40 years or younger, 80% versus 60%; 41 to 50 years, 91% versus 61%; 51 to 60 years, 84% versus 69%; 61 to 70 years, 95% versus 75%. The older than 70-year group was 100% versus 92% (no significant difference). The actual freedom from structural valve deterioration also demonstrated the same pattern at 10 years: 40 years or younger, CE-P 82% versus CE-SAV 68%; 41 to 50 years, 92% versus 70%; 51 to 60 years, 90% versus 80%; 61 to 70 years, 97% versus 88%; and older than 70 years, 100% versus 97%. The independent risk factors of structural valve deterioration for the overall mitral valve replacement group were age and age groups and prosthesis type (CE-SAV > CE-P). The prosthesis type either in isolated replacement or in multiple replacement was not predictive of structural valve deterioration. The pathology of structural valve deterioration was different: 70% of CE-P failures were due to calcification and 57% of CE-SAV failures were due to combined calcification and leaflet tear. CONCLUSION: The actuarial and actual freedom from structural valve deterioration, diagnosed at reoperation, is greater at 10 years for CE-P than for CE-SAV bioprostheses. The mode of failure is different, and the cause remains obscure. Long-term evaluation is recommended, because the different modes of failure may alter the clinical performance by 15 and 20 years.     

Acute early failure of a bioprosthesis after mitral valve replacement with completely preserved annuloventricular continuity

We report a case of acute early bioprosthetic failure after mitral valve replacement with completely preserved annuloventricular continuity. A 77-year-old man with left ventricular dysfunction underwent double valve replacement with Carpentier-Edwards pericardial bioprostheses. Routine postoperative echocardiography revealed 1.4 cm² of estimated mitral valve area, and computed tomography revealed a large thrombus in the left atrium. Transesophageal echocardiography showed a restricted opening of the bioprosthetic leaflets. After a month of strict anticoagulation therapy, cusp mobility improved, with a calculated mitral valve area of 3.5 cm²; and the left atrial thrombus had almost disappeared 2 months after initiation of therapeutic anticoagulation. Surgeons should be watchful for bioprosthetic thrombosis in patients with left ventricular dysfunction who undergo mitral valve replacement with a preserved mitral subvalvular apparatus.     

Valve-in-valve replacement of primary tissue valve failure of bovine pericardial valve minor

A 73-year-old woman who underwent mitral valve replacement with a 31 mm Carpentier Edwards Pericardial Xenograft 19 years ago. She revealed sudden onset of a grade IV/VI a seagull like diastolic murmur at the apex, and severe hematuria. Echocardiography demonstrated severe mitral regurgitation. These findings were consistent with acute primary tissue valve failure. Therefore we performed emergency reoperation. At operation, valve leaflet was torn at the commissural stitch, and bioprosthesis strut was buried in the left posterior ventricular wall. The mitral prosthetic valve replaced with a 25 mm CarboMedics OptiForm using a technique of valve-in-valve replacement. This procedure would be one option for replacement of bioprosthetic mitral valve.     

Perivalvular leakage 25 years after initial mitral valve replacement with a Björk-Shiley prosthesis

An 80-year-old woman had undergone initial mitral valve replacement using a Björk-Shiley mechanical valve owing to mitral stenosis 25 years earlier. Suddenly, she had anemia and an increased lactic dehydrogenase (LDH) level. Transesophageal echography (TEE) showed perivalvular leakage. In a redo operation, two side-by-side stitches of the valve on the posterior annulus were loosened without cutting and the sewing cuff at that site was floated over the annulus, leading to the perivalvular leakage. The valve was easily removed; and round, hard, degenerative calcified tissue composed of remnant mitral valve in the suture site during the initial operation was found just under the sewing cuff. After resection of this calcified round tissue, a 25-mm bioprosthesis was put in place. Her postoperative recovery was uneventful, and 47 days after surgery she was discharged without perivalvular leakage or anemia.     

A case report: Carpentier-Edwards porcine bioprosthesis malfunction due to the stent dehiscence at 17 years after the implantation in the mitral position

A 53-year-old female had undergone mitral valve replacement with Carpentier-Edwards (C-E) porcine bioprosthesis for mitral valve regurgitation at the other hospital in November, 1981. Postoperative clinical course was uneventful, since she was referred from the other hospital in 1990. In December, 1997, she had sudden complaint of shortness of breath on effort, and the chest X-ray showed pulmonary congestion and increase of cardio-thoracic ratio. Echocardiography and catheterization revealed severe mitral regurgitation due to bioprosthesis malfunction and aortic valve regurgitation. Combined mitral and aortic valve replacement was successfully performed with mechanical valves in February, 1998. The explanted C-E porcine bioprosthesis showed the commissural dehiscence from only one of the three stents without any leaflet perforation, commissural tear, pannus overgrowth, impaired leaflet mobility and leaflet deterioration or calcification. This case suggested the variety of malfunction of C-E porcine bioprosthesis and the limitation of its long-term durability.     

Ventricular function following mitral valve surgery: assessment using radionuclide ventriculography

The effects of mitral valve replacement or commissurotomy on cardiac function were studied using radionuclide ventriculography in 13 patients with chronic mitral stenosis and in 8 with chronic mitral regurgitation, before and after mitral valve surgery. The stenosis resulted from rheumatic heart disease in all instances while regurgitation was due to mitral valve prolapse in three patients and rheumatic heart disease in five. Fourteen patients had a Carpentier-Edwards valve inserted and 4 a Lillehei-Kaster disc valve. Three patients with mitral stenosis had an open commissurotomy. All patients underwent supine-rest and symptom-limited exercise radionuclide ventriculography shortly before and 6 to 12 months after operation. The data obtained showed that left ventricular function remained unchanged postoperatively in patients with mitral stenosis but deteriorated in those with mitral regurgitation. Right ventricular function improved postoperatively in those with mitral stenosis but remained unchanged in patients who had regurgitation.     

Long-term results of bioprosthetic mitral valve replacement: the pericardial perspective

Pericardial valve bioprostheses were introduced in early 1970s and were widely used in the 1980s. The longterm results with the Ionescu-Shiley valve, the first commercially available pericardial valve, were disappointing because of high rate cusp tears during the first decade after implantation. The enthusiasm for this type of bioprosthetic valve was further hampered by the premature failure of the Hancock pericardial valve. The long-term results of aortic valve replacement with the Carpentier-Edwards pericardial valve, which was introduced in 1981, indicated that that valve was durable and the issue of cusp tears had been resolved by an appropriate design. This knowledge prompted surgeons to revisit the merits of pericardial valves for mitral valve replacement and several other pericardial valves are now commercially available. The largest data on long-term results are with the Carpentier-Edwards pericardial mitral valve. The reported freedom from structure valve failure ranged from 69% to 85% at 10 years in patient population with mean age of 60 to 70 years. Young age is a major determinant of valve failure, which is largely due to calcification. There are also long-term data, albeit more limited on the Sorin Pericarbon and Mitroflow valves used for mitral valve replacement. This paper review the published experience with various pericardial bioprosthetic valves used for mitral valve replacement during the past 3 decades.     

A surgical case for severe hemolytic anemia after mitral valve repair.

We report a rare case of severe hemolytic anemia accompanied by moderate renal insufficiency after mitral valve repair. Although the degree of the residual mitral regurgitation was less than 1+ during the first three weeks after the operation, the maximum lactate dehydrogenase (LDH) was up to 7,430 U/l and the minimum hemoglobin was 4.9 g/dl. The mitral valve replacement successfully resolved the hemolysis, but the renal function did not completely recover.     

Rapidly deteriorated failure of Carpentier-Edwards porcine bioprosthesis caused by three detached commissures: Report of a case

A 58-year-old man required an emergency redo mitral valve replacement due to a rapidly deteriorating failure of the Carpentier-Edwards porcine bioprosthesis only a few days after the initial operation. The removed bioprosthesis showed that its three commissures had all peeled off each stent, which may have occurred within a short time, and caused massive, rapidly progressive trans-bioprosthesic regurgitation.