Bioprosthetic mitral valve thrombosis less than one year after replacement and an ablative MAZE procedure: a case report

Occurrence of bioprosthetic valve thrombosis less than a year after replacement is very uncommon. Here, we describe a case of a 57 year old male, who presented 10 months after receiving a bioprosthetic mitral valve replacement with a two week history of dyspnea on exertion, worsening orthopnea and decreased exercise tolerance. Echocardiography revealed severe mitral regurgitation (MR), thrombosis of the posterior mitral leaflet, left atrial (LA) mural thrombus and a depressed left ventricular ejection fraction of twenty-five percent. Given severe clot burden and decompensated heart failure (New York Heart Association - NYHA class III) repeat sternotomy was done to replace the bioprosthetic mitral valve and remove LA mural thrombus. MR was resolved postoperatively. This brief report further reviews promoting factors, established guidelines and management strategies of bioprosthetic valve thrombosis.     

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 bioprosthetic mitral valve stenosis in a patient with HITS

Acute thrombosis involving the left atrium and a bioprosthetic valve during the early postoperative period is an extremely rare complication of heparin-induced thrombocytopenia syndrome (HITS). We present a patient with early bioprosthetic mitral valve stenosis complicated by HITS in a patient with severe mitral regurgitation, atrial fibrillation, and severe left ventricular dysfunction.     

Early bioprosthetic mitral valve "pseudostenosis" after complete preservation of the native mitral apparatus

An advantage of bioprosthetic mitral valve replacement in patients with normal sinus rhythm is avoidance of the need for long-term anticoagulation. Bioprosthetic valve thrombosis is a rare complication, supporting this approach. This case report represents an example of porcine mitral valve stenosis, likely secondary to thrombosis, in which all of the native mitral valve apparatus was left intact. This was successfully treated with standard anticoagulation therapy. This complication should be considered in patients in whom retention of the mitral valve apparatus has been performed. Such patients may benefit from long-term anticoagulation treatment to obviate this event.     

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.     

Enlarged coronary sinus thrombosis after repair of Ebstein's anomaly

A 58-year-old woman was referred to our hospital with progressively increasing breathlessness. She reported a history of bioprosthetic valve implantation for tricuspid valve replacement and direct closure of an atrial septal defect for Ebstein's anomaly, 31 years before presentation. Transthoracic echocardiography revealed prosthetic valve failure, an enlarged coronary sinus, and severe mitral regurgitation. Computed tomography revealed a giant coronary sinus with thrombosis and persistent left superior vena cava. She underwent successful mitral and tricuspid valve replacement; however, severe hemodynamic deterioration necessitated mechanical ventilatory support with extracorporeal membrane oxygenation.     

Comparison of outcomes after mitral valve replacement with a mechanical versus a bioprosthetic valve in patients between forty and sixty years of age

Background  The American College of Cardiology/American Heart Association (ACC/AHA), guidelines for choice of prosthetic valve based on patients’ age are difficult to apply to the developing world because of a lower life expectancy and difficulty in maintaining correct levels of anticoagulation for a variety of reasons. While there is general agreement on the choice of prosthetic valves for patients below 40 years of age (mechanical) and above 60 years of age (biologic), the 40 to 60 age group remains a grey zone. The goal of our study was to compare outcomes after mitral valve replacement with a mechanical versus a bioprosthetic valve in patients between forty and sixty years of age. Methods  From Jan 2003 to July 2008, 250 patients between the ages of 40 and 60, undergoing mitral valve replacement at our institution were randomized to receive either a mechanical or a bioprosthetic valve. Outcomes in the form of incidence of valve thrombosis and thromboembolism, bleeding complications, incidence of prosthetic valve endocarditis and survival were compared in the two groups. Results  Out of 250 patients, 135 patients received mechanical valve and 115 patients were implanted with a bioprosthetic valve. Patients were followed up for a mean period of 3 years (range 6 months to 4.8 years). The incidence of valve thrombosis was higher in mechanical valve as compared to bioprosthetic valve (6% vs. 0.9%, p= 0.04). Similarly there was a higher incidence of thromboembolism in mechanical valves as compared to bioprosthetic valves (4.5% vs. 0%, p=0.03). Bleeding complications occurred more frequently in mechanical than bioprosthetic valve (6% vs. 0.9%, p=0.04). There was no significant difference in the incidence of prosthetic valve endocarditis (2.2% vs. 2.7%, p >0.05) or survival at three years (96.2% vs. 97.2%, p > 0.05) in the two groups. Conclusions  Patients in the age group of 40 to 60 years undergoing mitral valve replacement with a mechanical valve have a higher incidence of thrombotic and bleeding complications as compared to bioprosthetic valve, even though short term survival is similar. This favours implantation of a bioprosthetic valve in this age group.     

A case of bioprosthetic mitral valvular dysfunction due to pannus-formation

A case of bioprosthetic mitral valvular dysfunction accompanied by mitral stenosis due to pannus is reported. A 69-year-old woman, whose mitral valve had been replaced with a Hancock bioprosthetic valve in June 1979, underwent the second mitral valve replacement in September 1988 because of valvular dysfunction. The ring and cusps of this Hancock valve was partially covered with hard and milky white pannus which resulted in mitral stenosis. The tear of cusp was observed at the point of contact with pannus, which resulted in mitral regurgitation. Histologically, pannus was consisted of two-layered structure, fibrin and collagen fiber, which demonstrated this over-growth was based on thrombus. Main causes of bioprosthetic valve dysfunction are calcification and tear of cusps. But, valvular dysfunction due to pannus-formation described in this case has been experienced very rarely.     

Results of reoperation for primary tissue failure of porcine bioprostheses

Results of reoperation for primary tissue failure of porcine bioprostheses were evaluated in 574 patients discharged from the hospital from 1970 to 1981. A total of 413 had undergone isolated mitral valve replacement and 161 isolated aortic valve replacement. Through March, 1984, 88 patients (15%) had required reoperation: 59 had undergone mitral and 29, aortic valve replacement. Primary tissue failure was the main cause of bioprosthetic dysfunction; it occurred in 64 patients (46 mitral and 18 aortic) at a mean postoperative interval of 93 +/- 4 months (range 34 to 158). During the same period, 11 patients required reoperation for bioprosthetic endocarditis, 11 for paravalvular leak, and two for thrombosis. These patients are not included in this review. Reoperation for primary tissue failure was performed after a mean interval of 72 +/- 6 months (range 38 to 158) for patients with aortic bioprostheses and after 101 +/- 5 months (range 34 to 153) for those with mitral bioprostheses (p less than 0.05). Overall mortality at reoperation was 12.5%: 11% for the mitral group and 16% for the aortic group. In 62 patients (45 mitral and 17 aortic) primary tissue failure was caused by calcification of the cusps, associated with severe fibrous tissue overgrowth in seven. Bioprosthetic failure was caused by an intracuspal hematoma in one patient with mitral valve replacement and by lipid infiltration of the cusps in one patient with aortic valve replacement. Actuarial freedom from bioprosthetic primary tissue failure at 12 years is 61% +/- 5% for the mitral group and 69% +/- 7% for the aortic group. On the basis of our long-term follow-up of patients after mitral or aortic replacement with a porcine bioprosthesis, we conclude: primary tissue failure is the most frequent indication for reoperation in patients with a porcine bioprosthesis; calcification of the cusp tissue is the leading cause of primary tissue failure; reoperation for primary tissue failure may be a major concern, although mortality for elective cases is low; and the limited durability of porcine bioprostheses suggests their use be restricted to selected patients.     

Direct transatrial transcatheter SAPIEN valve implantation through right minithoracotomy in a degenerated mitral bioprosthetic valve

Transcatheter valve implantation into failing surgical mitral bioprosthetic valves have been reported. This strategy avoids performing high-risk repeat cardiac surgery in elderly patients with multiple comorbidities. All these patients have been treated by a transapical approach. We report a case of failing bioprosthetic mitral valve in an 82-year-old woman successfully treated with a 29-mm Edwards SAPIEN balloon expandable bioprosthesis (Edwards Lifesciences, Irvine, CA) with direct left atrial approach through a right anterior thoracotomy. Our experience demonstrates the technical feasibility and safety of this approach. Therefore, mitral valve-in-surgical valve implantation may be a viable treatment alternative in carefully selected patients.     

老年风湿性二尖瓣病变行二尖瓣修复术与生物瓣膜置换术中期效果比较

目的比较60岁以上老年患者风湿性二尖瓣修复(MVP)与生物瓣膜置换(MVR)的中期效果。方法选取2014年1月至2016年1月北京安贞医院瓣膜外科诊疗中心行风湿性二尖瓣修复或生物瓣置换手术的60岁以上老年风湿性二尖瓣病变患者,包括同期行三尖瓣修复术及房颤射频消融术患者;排除合并主动脉瓣手术、冠状动脉旁路移植手术、二次手术患者,最终纳入患者82例。根据二尖瓣手术方式分为二尖瓣修复组(MVP组,25例)和生物瓣置换组(MVR组,57例)。采用Kaplan-Meier法进行生存分析并绘制曲线,通过Log Rank方法比较两组患者5年生存率的差异。结果围手术期全组患者平均年龄(66.37±4.41)岁。54.9%的患者心功能(NYHA分级)Ⅲ级。两组患者在体外循环时间(P=0.99),主动脉阻断时间(P=0.88),术后住院时间(P=0.76)差异均无统计学意义。MVR组3例患者住院期间死亡,病死率5.3%;MVP组无住院期死亡(P=0.24)。随访5年,最长随访63个月,平均随访47.03个月。MVR组6例死亡,其中4例死于心脑血管不良事件,2例死于非心脑血管不良事件。MVP组无死亡。两组均无再手术病例。结论风湿性二尖瓣病变的老年患者采用二尖瓣修复手术治疗能够获得较好的中期效果。     

Pannus Resection Through the Tilting Disc Prosthesis: Successful Treatment Preserving the Prosthesis

Abstract: A 59-year-old woman was admitted to our hospital because of heart failure. In 1988, she underwent aortic valve replacement with an Omnicarbon valve and mitral valve replacement with a bioprosthetic valve. She was doing well until July in 1996 when she developed heart failure. Echocardiography revealed massive mitral valve regurgitation, and cinefluoroscopy showed implanted Omnicarbon valve dysfunction with a leaflet opening angle of 35 degrees. At reoperation, it was revealed that pannus formation prevented the valve from functioning well. The pannus was resected through the major orifice, and the leaflet was rotated toward the right anterolateral orientation. The worn bioprosthetic valve was replaced with a mechanical one. Postoperative cinefluoroscopy of the rotated Ominicarbon valve showed the opening angle to be 61 degrees.     

Severe bioprosthetic mitral valve stenosis in pregnancy

A 21-year-old woman in the 16th week of pregnancy was admitted due to acute presentation of severe exertional dyspnea. She had undergone mitral valve replacement (MVR) with bioprosthetic valve for infective endocarditis 2 years ago. She developed congestive heart failure from mitral bioprosthetic valve stenosis due to early structural valve deterioration. She also had severe pulmonary hypertension and underwent a redo MVR using a mechanical valve prosthesis with good maternal outcome but fetal demise. This report brings up the debate about what type of valve should be used in women in reproductive age, and discusses the management of severe mitral stenosis and stenosis of a bioprosthetic valve during pregnancy. Surgical options can almost always be delayed until fetal maturity is achieved and a simultaneous cesarean section can be performed. However, under certain circumstances when the maternal welfare is in jeopardy the surgical intervention is mandatory even before the fetus reaches viability.     

Endoventricular pocket repair of type I myocardial rupture after mitral valve replacement: a new technique using pericardial patch, Teflon felt, and BioGlue

Left ventricular (LV) rupture is an infrequent but potentially lethal complication of mitral valve replacement and repair. We report the case of an 82-year-old man who underwent mitral valve replacement and the repair of an atrial septal defect. Both valve leaflets were excised and the annulus was extensively decalcified, followed by the implantation of a bioprosthetic valve. LV rupture was diagnosed after weaning from cardiopulmonary bypass (CPB). CPB was resumed and the bioprosthetic valve was removed. The patient then underwent a unique repair using a pericardial patch, Teflon felt (Meadox Medical Inc, Oakland, NJ), and BioGlue (CryoLife Inc, Kennesaw, GA). A second valve was implanted with a successful outcome.     

Hammock mitral valve in an adult patient

We describe a case of hammock mitral valve in an adult. A 38-year-old woman presented with recently acquired dyspnea. Echocardiography showed severe mitral stenosis related to a hammock mitral valve characterized by the presence of an overdeveloped papillary muscle that gives short chordae to both mitral leaflets. No other valve insufficiency was noted. At operation, we observed direct continuity accompanying several fenestrations between both leaflets and the huge abnormal muscular band just underneath the mural leaflet. Resection of the anterior leaflet and was successfully replaced with a bioprosthetic valve. Her postoperative course was unremarkable.     

Early degeneration of a bioprosthetic mitral valve complicated by a large left atrial thrombus

The authors report the case of a patient with symptomatic early bioprosthetic mitral valve deterioration in the setting of calcium supplementation. This was further complicated by a large left atrial thrombus despite supratherapeutic anticoagulation and a previously oversewn left atrial appendage. As mechanical valves are less predisposed to calcification in comparison with bioprosthetic implants, the patient underwent a mechanical mitral valve replacement in addition to a left atrial thrombectomy.     

Necessity of permanent anticoagulant therapy for isolated mitral valve replacement with bioprosthetic heart valve to prevent the postoperative thromboembolic complications

One hundred fifty four patients underwent isolated mitral valve replacement with bioprosthetic heart valve at Hyogo Medical College Hospital from November 1973 to December 1998. A porcine bioprosthetic valve was replaced in 82 patients (Hancock 43, Carpentier-Edwards 26, Hancock II 13) and pericardial bioprosthetic valve in 72 patients (Ionescue-Shiley 39, Carpentier-Edwards 33) with a mean follow-up of 1,410 patients-years. Their thromboembolism rates were also analyzed in linear and actuarial term over the 15-year period. The incidence of thromboembolism rate was 2.5%/pt.yr. Thromboembolic free rates for patients with anticoagulant therapy were significantly decreased for patients without therapy. Thromboembolic free rates for patients with atrial fibliration were also were significantly decreased for patients with sinus rhythm because the patients with sinus rhythm were not on anticoagulant therapy. In conclusion, it is necessary for the all patients to be on anticoagulant therapy after mitral valve replacement with bioprosthetic valves, even though patients with sinus rhythm.     

Risk of Reoperative Valve Replacement for Failed Mitral and Aortic Bioprostheses

Background. One factor influencing the choice of mechanical versus bioprosthetic valves is reoperation for bioprosthetic valve failure. To define its operative risk, we reviewed our results with valve reoperation for bioprosthetic valve failure.

Methods. Records of 400 consecutive patients having reoperative mitral, aortic, or mitral and aortic bioprosthetic valve replacement from January 1985 to March 1997 were reviewed.

Results. Reoperations were for failed bioprosthetic mitral valves in 219 patients, failed aortic valves in 153 patients, and failed aortic and mitral valves in 28 patients. Including 26 operations (6%) for acute endocarditis, 153 operations (38%) were nonelective. One hundred nine patients (27%) had other valves repaired or replaced, and 72 (18%) had coronary bypass grafting. The incidence of death in the mitral, aortic, and double-valve groups was respectively, 15 (6.8%), 12 (7.8%), and 4 (14.3%); and the incidence of prolonged postoperative hospital stay (>14 days) was, respectively, 57 (26.0%), 41 (26.8%), and 8 (28.6%). Only 7 of 147 patients (4.8%) having elective, isolated, first-time valve reoperation died. Multivariable predictors (p < 0.05) of hospital death were age greater than 65 years, male sex, renal insufficiency, and nonelective operation; and predictors of prolonged stay were acute endocarditis, renal insufficiency, any concurrent cardiac operation, and elevated pulmonary artery systolic pressure.

Conclusions. Reoperative bioprosthetic valve replacement can be performed with acceptable mortality and hospital stay. The best results are achieved with elective valve replacement, without concurrent cardiac procedures.     

Replacement of degenerated mitral and aortic bioprostheses without explantation.

BACKGROUND: The most common indication for reoperation in patients with a bioprosthetic valve is primary tissue failure. Explantation of the bioprosthesis is time consuming, and for a mitral valve, may be complicated by cardiac rupture at the atrioventricular junction or the posterior left ventricular wall where a strut is imbedded, injury to the circumflex artery, and late perivalvular leak; for an aortic valve, annular disruption and perivalvular leak may complicate explantation. A new approach to simplify these procedures and avoid these complications, by excising only the bioprosthetic tissue and attaching a bileaflet mechanical valve to the intact stent, was developed in 1991 and was evaluated over a 9-year period in 50 patients who had had one (34), two (10), three (4), or four (2) previous open cardiac operations. METHODS: Since 1991, we have replaced degenerated mitral bioprostheses in 34 patients (25 to 84 years of age; 12 male, 22 female) by preserving the stent and suturing a St. Jude or Carbomedics bileaflet valve to the atrial side of the bioprosthetic cuff; the mitral valve was exposed through a median sternotomy in 21 patients and through a right anterolateral thoracotomy in 13. Using a similar approach, starting in 1995, 16 additional patients (55 to 73 years of age; 11 male, 5 female) with degenerated aortic bioprostheses had the aortic valve replaced by excising the bioprosthetic tissue and amputating the struts, then suturing a Carbomedics valve to the aortic side of the bioprosthetic cuff. This allows the use of a bileaflet valve similar in size to the bioprosthesis with exact matching of the orifices. RESULTS: Bypass time averaged 61 +/- 14 minutes and aortic cross-clamp time 43 +/- 12 minutes. There has been no operative mortality. Three late deaths occurred at 9, 37, and 58 months, and were not valve related. No gradients of hemodynamic significance have been detected on transesophageal echocardiographic follow-up. CONCLUSIONS: Leaving the bioprosthetic cuff intact eliminates the need for extensive dissection, thus shortening and simplifying the procedure and diminishing its attendant mortality and morbidity. This valve-on-valve approach also allows replacement of a degenerated bioprosthesis with a bileaflet valve of comparable size rather than a smaller one jammed into the orifice of the bioprosthetic stent, thus avoiding undue trauma to the bileaflet valve and maintaining excellent hemodynamic function.     

Cardiac valve replacement in patients on dialysis: influence of prosthesis on survival

BACKGROUND: Mechanical valves have been recommended for patients on dialysis because of purported accelerated bioprosthesis degeneration. This study was undertaken to determine time-related outcomes in dialysis patients requiring cardiac valve replacement. METHODS: From 1986 to 1998, 42 patients on chronic preoperative dialysis underwent valve replacement; 17 received mechanical valves and 25 received bioprostheses. Age was similar in both groups: 54+/-18.5 years (mechanical) and 59+/-15.5 years (bioprosthetic, p = 0.4). Sites of valve replacement were aortic (27), mitral (11), and aortic and mitral (4). Follow-up was 100% complete. RESULTS: Survival at 3 and 5 years was 50% and 33% after mechanical valve replacement, and 36% and 27% after bioprosthetic valve replacement (p = 0.3). Four patients with bioprostheses required reoperation: 3 for allograft endocarditis and 1 at 10 months for mitral bioprosthesis degeneration. One patient who received a mechanical valve required reoperation. CONCLUSIONS: Prosthetic valve-related complications in patients on dialysis were similar for both mechanical and bioprosthetic valves. Because of the limited life expectancy of patients on dialysis, bioprosthesis degeneration will be uncommon. Therefore, surgeons should not hesitate to implant bioprosthetic valves in these patients.