Reoperation due to failure of a Freestyle bioprosthesis

We report re-do aortic valve and ascending aorta replacements by using the valve-on-valve technique for primary tissue failure of a Freestyle bioprosthesis. A 74-year-old male, who had had a 25 mm Freestyle bioprosthetic valve implanted by the sub-coronary method 5 years previously for aortic valve regurgitation due to congenital bicuspid valve, was referred to our hospital for dyspnea and palpitation. He presented with heart failure secondary to aortic regurgitation due to primary tissue failure, and computed tomography demonstrated an enlarged ascending aorta (5 cm in diameter). The operative findings revealed that the Freestyle bioprosthetic valve had a leaflet tear at the left coronary cusp. We replaced the degenerated Freestyle bioprosthesis with a 19 mm Mosaic aortic bioprosthesis by using the valve-on-valve technique, and ascending aorta replacement was performed simultaneously. This technique can be useful for re-do surgery for degenerated stentless valves to avoid potential risks of complete excision of the bioprosthesis.     

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.     

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.     

Delayed rupture of the left ventricle after mitral valve replacement with bioprosthesis.

Rupture of the posterior ventricular wall after mitral valve replacement is a complication rarely reported in the literature. Perforation of the left ventricle after mitral valve replacement with a bioprosthesis has been described in only 3 patients. We have had 2 patients with this complication out of 322 patients who had mitral valve replacement with bioprosthesis. These perforations were caused by impingement of the posterior strut of the bioprosthesis on the posterior left ventricular wall, with intramyocardial hematoma and delayed rupture of the left ventricle.     

New approach for replacement of degenerated mitral bioprostheses

OBJECTIVE: The most common indication for reoperation in patients with a mitral bioprosthetic valve is primary tissue failure. Explanation of the bioprosthesis is time-consuming and 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. A new approach to avoid these complications by excising only the bioprosthetic tissue and attaching a reversed aortic St. Jude valve to the intact stent has been developed and evaluated. METHODS: We have replaced degenerated mitral bioprostheses with a St. Jude valve in 73 patients during the last 12 years. In 57, including all who had their operation before 1991, explantation was used. The stent was preserved in 16 patients; in the first four we implanted a mitral St. Jude valve (SJM) within the stent, but this only allows a SJM 6-8 mm smaller than the bioprosthesis. We evolved our approach in the last 12 patients to suture a reversed aortic St. Jude valve with extended cuff to the atrial side of the bioprosthetic cuff; this allows the use of a St. Jude valve 2 mm smaller than the bioprosthesis with exact matching of the orifice sizes. The demographic and clinical profiles of the two groups were similar. RESULTS: Operative mortality was 8/57 (14%) in the explantation group and none in the stent-preservation group. Three late perivalvular leaks occurred in the explanation group, and none in the stent-preservation group. Thirteen late deaths occurred in the explanation group, with a 5-year survival rate of 68%, and one late death (cancer) in the stent-preservation group, but the follow-up is significantly shorter. CONCLUSIONS: Leaving the mitral bioprosthetic stent and cuff intact eliminates the need for extensive dissection, thus shortening and simplifying the procedure and diminishing its attendant mortality and morbidity. It offers a safe and logical approach to replacement of a degenerated mitral bioprosthesis with a St. Jude valve of comparable size which projects into the left atrium, rather than a smaller one jammed into the orifice of the bioprosthetic stent.     

Use of the Alfieri edge-to-edge technique to eliminate left ventricular outflow tract obstruction caused by mitral systolic anterior motion

A 68-year-old woman with concentric left ventricular hypertrophy, prosthetic valve endocarditis with aortic root abscess, and sepsis had aortic root replacement with an aortic allograft. On weaning from cardiopulmonary bypass, she had hemodynamic instability caused by systolic anterior motion of the mitral valve, which resulted in a left ventricular outflow tract obstruction; the peak pressure gradient across the left ventricular outflow tract was 130 mm Hg, and there was moderately severe (3+) mitral regurgitation. After reinstitution of cardiopulmonary bypass, a central Alfieri edge-to-edge stitch was placed between the anterior and posterior leaflets of the mitral valve. This reduced the gradient across the left ventricular outflow tract to 10 mm Hg and eliminated the mitral regurgitation, which enabled successful separation from cardiopulmonary bypass.     

Mitral valve repair for a broad prolapse in the high posterior leaflet

We report a mitral valve repair for a broad prolapse in the high posterior leaflet. Prolapse in the high redundant posterior leaflet with elongation of the chordae had caused the severe mitral valve regurgitation in a 45-year-old man. At operation, the prolapsed portion of the middle scallop was quadrangularly resected in 22 mm wide and 17 mm high. We combined the sliding leaflet technique with the posterior leaflet folding plasty to reduce the height of the posterior leaflet and to lessen the degree of mitral annular plication. Mitral valve regurgitation disappeared after the operation. No left ventricular outflow obstruction associated with systolic anterior motion and no injury to the left circumflex artery were confirmed. These procedures after a broad resection of the high posterior leaflet could successfully prevent systolic anterior motion and injury to the left circumflex artery, and reduce the stress on the suture line of the leaflet.     

Valve-on-valve technique for replacement of degenerated tricuspid bioprosthetic valve without explantation

A 73-year-old woman admitted to our hospital with shortness of breath and edema of the lower extremities was diagnosed with right ventricular failure stemming from tricuspid valve regurgitation. She had undergone mitral valve replacement (MVR) with a mechanical valve at the age of 51, and reoperative MVR with mechanical valve, tricuspid valve replacement (TVR) with bioprosthetic valve, and pacemaker implantation at the age of 63. Reoperative TVR was performed when the patient failed to respond to drug therapy. A beating heart cardiopulmonary bypass procedure was performed in which only the bioprosthetic valve leaflet was excised, and reoperative TVR was performed with a 27-mm OptiForm^TM mechanical mitral valve (Sulzer Carbomedics Inc., Austin, TX, USA) by the valve-on-valve technique. The operative course was uneventful. The technique used here appears to be an effective approach to reoperative TVR, in this instance making it possible to avoid the risks associated with excision of the old prosthesis.     

Systolic anterior motion of the mitral valve despite the sliding leaflet technique for repair of the mitral valve

We report a systolic anterior motion of the anterior mitral leaflet despite employing the sliding leaflet technique for repair of mitral valve regurgitation. A 65-year-old man with chronic, symptomatic mitral regurgitation due to ruptured chordae tendineae underwent mitral valve repair by quadrangular resection of the posterior leaflet and sliding leaflet technique with ring annuloplasty. After weaning from cardiopulmonary bypass, left ventricular outflow obstruction developed and transesophageal echocardiography demonstrated systolic anterior motion of the mitral valve and severe mitral regurgitation. Non-operative treatment resolved the outflow tract obstruction, systolic anterior motion and mitral regurgitation. We conclude that post-repair systolic anterior motion can still occur after the sliding plasty procedure and that medical treatment can successfully resolve systolic anterior motion and outflow tract obstruction in most patients.     

A staged approach to transcatheter aortic valve implantation and mitral valve-in-valve implantation for a degenerated bioprosthesis in a high-risk patient

Recently, small case series have described the successful off-label use of transcatheter valve implantation in patients with degenerated bioprosthetic valves in the mitral position. We report here the case of a 78-year old female patient who underwent transcatheter aortic valve implantation for severe aortic stenosis and transapical valve-in-valve implantation for a degenerated mitral bioprosthesis. There was no evidence of intraprosthetic regurgitation and/or paraprosthetic leakages on control angiography and transoesophageal echocardiography. The postoperative course was uneventful. Following accurate patient selection and evaluation by an experienced multidisciplinary team, the transcatheter approach to double-valve implantation in the aortic and mitral positions may represent a viable treatment option for those high-risk patients who would otherwise be inoperable. We preferred a two-step approach, considering a single procedure to be high-risk.     

Mitral valve re-replacement in a patient with occlusion of the left internal carotid artery

An 83-year-old female patient, who had previously undergone mitral valve replacement using bioprosthesis at 15 years ago, presented symptoms of congestive heart failure. Mitral valve regurgitation was caused by structural deterioration of the bioprosthetic valve, and replacement of the bioprosthesis was indicated. Digital subtraction angiography revealed occlusion of the left internal carotid artery, which put this patient at high risk to cerebral complications during heart valve surgery. Administration of acetazolamide induced a marked decrease in the blood flow in the left cerebral hemisphere. Re-replacement of the mitral valve was successfully performed under high-flow cardiopulmonary bypass. Intra-aortic balloon pumping produced pulsatile blood flow with a peak pressure of 90-100 mmHg during the cardiopulmonary bypass. She recovered after surgery with no neurological complication. We believe the pulsatile cerebral perfusion produced by the intra-aortic balloon pumping with high-flow cardiopulmonary bypass was effective for preventing cerebral complications in this patient with internal carotid artery occlusion.     

Ischemia in three left ventricular regions: Insights into the pathogenesis of acute ischemic mitral regurgitation

BACKGROUND: Acute posterolateral left ventricular ischemia in sheep results in ischemic mitral regurgitation, but the effects of ischemia in other left ventricular regions on ischemic mitral regurgitation is unknown. METHODS: Six adult sheep had radiopaque markers placed on the left ventricle, mitral annulus, and anterior and posterior mitral leaflets at the valve center and near the anterior and posterior commissures. After 6 to 8 days, animals were studied with biplane videofluoroscopy and transesophageal echocardiography before and during sequential balloon occlusion of the left anterior descending, distal left circumflex, and proximal left circumflex coronary arteries. Time of valve closure was defined as the time when the distance between leaflet edge markers reached its minimum plateau, and systolic leaflet edge separation distance was calculated on the basis of left ventricular ejection. RESULTS: Only proximal left circumflex coronary artery occlusion resulted in ischemic mitral regurgitation, which was central and holosystolic. Delayed valve closure (anterior commissure, 58 +/- 29 vs 92 +/- 24 ms; valve center, 52 +/- 26 vs 92 +/- 23 ms; posterior commissure, 60 +/- 30 vs 94 +/- 14 ms; all P <.05) and increased leaflet edge separation distance during ejection (mean increase, 2.2 +/- 1.5 mm, 2.1 +/- 1.9 mm, and 2.1 +/- 1.5 mm at the anterior commissure, valve center, and posterior commissure, respectively; P <.05 for all) was seen during proximal left circumflex coronary artery occlusion but not during left anterior descending or distal left circumflex coronary artery occlusion. Ischemic mitral regurgitation was associated with a 19% +/- 10% increase in mitral annular area, and displacement of both papillary muscle tips away from the septal annulus at end systole. CONCLUSIONS: Acute ischemic mitral regurgitation in sheep occurred only after proximal left circumflex coronary artery occlusion along with delayed valve closure in early systole and increased leaflet edge separation throughout ejection in all 3 leaflet coaptation sites. The degree of left ventricular systolic dysfunction induced did not correlate with ischemic mitral regurgitation, but both altered valvular and subvalvular 3-dimensional geometry were necessary to produce ischemic mitral regurgitation during acute left ventricular ischemia.     

Transventricular mitral valve operations

We report transventricular mitral valve operations in 2 patients with severe mitral regurgitation and postinfarction left ventricular rupture and pseudoaneurysm. The first patient had direct papillary muscle involvement necessitating replacement of the mitral valve. The second patient had indirect mitral involvement allowing for placement of an atrial mitral annuloplasty ring via the left ventricle. Both patients showed no mitral valve regurgitation after replacement or repair and had uneventful postoperative recoveries. These cases demonstrate a feasible, alternative, transventricular approach to mitral valve replacement and repair.     

Mitral valve replacement and papillary muscle approximation after ineffective cardiac resynchronization therapy in a patient with adriamycin-induced cardiomyopathy

We report a case of adriamycin-induced cardiomyopathy with severe functional mitral regurgitation and congestive heart failure (CHF). Mitral valve replacement (MVR) and papillary muscle approximation (PMA) were effective for this case. A 68-year-old man had adriamycin-induced cardiomyopathy and had required repetitive hospitalizations for CHF for the past 10 years. He also required additional CHF hospitalizations after implantation of a device to perform cardiac resynchronization therapy. His echocardiogram showed severe mitral regurgitation and reduced left ventricular function. We performed MVR and PMA for his functional mitral regurgitation. We preserved the tendinous cords of the anterior and posterior leaflets of the mitral valve. His echocardiogram showed improved left ventricular systolic function and reduced left ventricular volume. He has made satisfactory progress after the operation and he has not required further hospitalizations for CHF. MVR with preservation of bilateral tendinous cords and PMA are very effective procedures for functional mitral regurgitation and intractable cardiomyopathy.     

Manouguian double-valve replacement in a 6-year-old girl

A 6-year-old girl with a diagnosis of aortic regurgitation with stenosis and mitral regurgitation because of short chordae was referred to us for surgery. Echocardiography revealed that the aortic and the mitral annular diameters were 16 and 23?mm, respectively. The Ross procedure and mitral valvuloplasty were scheduled. During the procedure, we were concerned that aggressive mitral valvuloplasty might result in mitral stenosis. We therefore converted the procedure to double-valve replacement using the Manouguian technique because it was necessary to enlarge both the aortic and mitral annuli. In children, the mitral prosthetic valve in Manouguian technique may override aortic annulus resulting in left ventricular outflow tract obstruction (LVOTO). Thus, it is important to decide the mitral prosthetic valve size. Measurements of both annuli showed 15 and 21?mm in aortic and mitral positions, respectively. Size #18 ATS AP mechanical valve (ATS Medical, Inc., Minneapolis, MN, USA) and size #23 ATS mechanical valve were implanted. We successfully performed two sizes up in the aortic position and one size up in the mitral position avoiding complications such as coronary orifice obstruction and LVOTO. To our knowledge, this is the youngest patient who underwent double-valve replacement by the Manouguian technique.     

Concomitant mitral valve repair and left ventricular reconstruction in a patient with chronic ischemic mitral regurgitation and inferior left ventricular aneurysm

The surgical approach to ischemic mitral regurgitation with concomitant inferior left ventricular aneurysm remains uncertain in terms of the indication for operation and the short-and long-term outcomes. We performed concomitant mitral valve repair, left ventricular reconstruction, and aortic valve replacement on a 71-year-old male with severe ischemic mitral regurgitation, inferior left ventricular aneurysm, and degenerative aortic regurgitation. Postoperative status was in New York Heart Association functional class I without mitral regurgitation 8 months after operation. We discuss, and review the procedures reported in the literature.     

Ventricular reconstruction results in improved left ventricular function and amelioration of mitral insufficiency

INTRODUCTION: Surgical restoration of the left ventricular wall (Dor procedure) has been advocated as a therapy for left ventricular dysfunction due to ischemic cardiomyopathy. This procedure involves placement of an endoventricular patch through a ventriculotomy. METHODS: We reviewed our series of patients that underwent the Dor procedure within the past 4 years and examined their pre and postoperative ventricular function and mitral valve function. Pre and postoperative ejection fraction and degree of mitral regurgitation were analyzed using the paired Student t-test. We hypothesized that this procedure would result in improved ventricular function and that it would also help improve mitral valve function. RESULTS: Thirty-four patients underwent this procedure, with one death. Of these, 30 patients underwent concomitant coronary artery bypass grafting and 8 patients had mitral intervention (seven had an Alfieri repair of the mitral valve, and one had mitral valve annuloplasty). The average preoperative ejection fraction among these patients was 26.8% (range 10-45%). The postoperative ejection fraction was significantly higher at 35.4% (range 25-52%) (P <.001). We noted an improvement in ejection fraction in 27 patients (82%). We also noted that 21 of 33 patients (64%) had improvement in the degree of mitral regurgitation based on echocardiography data (P <.001). CONCLUSIONS: We conclude that the Dor procedure results in improvement in the left ventricular function. Furthermore, we also note that this procedure ameliorates mitral regurgitation in a majority of these patients even in the absence of associated mitral valve procedures, probably due to reduction in the size of the ventricle and improved orientation of the papillary muscles.     

Left ventricular rupture after mitral valve replacement.

BACKGROUND: What are the immediate and long term outcomes of patients who had rupture of the left ventricle after mitral valve replacement? METHODS: Experimental design: A retrospective study with a 20-year follow-up. Setting: Experience in a single tertiary referral cardiothoracic surgery hospital. Participants: 20 out of 3105 patients that received mitral valve replacement. INTERVENTION: All these 20 patients received re-exploration for a trial of repair of left ventricular rupture either by an internal or an external or a combined repair. MEASURES: Operative mortality and long term outcome of the survivals. RESULTS: Most patients (16.80%) were female and had rheumatic mitral valve disease. The mean age of the patients was 58.1 years. All patients underwent attempted repair, usually by removal of the prosthesis and reconstitution of the ventricle from within the left atrium (75%). Thirteen (65%) patients died. Two late deaths were of unrelated cause. One surviving patient developed a late ventricular false aneurysm but did not undergo repeat surgery. One patient developed severe mitral regurgitation due to tissue failure of the bioprosthesis 12 years after surgery and she underwent a successful reoperation. CONCLUSIONS: We believe that all patients should be placed back on cardiopulmonary bypass for an internal repair. The long term outcome of the survivals is satisfactory.     

Mitral valve replacement with preservation of ventricular annular continuity

We evaluated clinical effects of mitral valve replacement with preservation of ventricular annular continuity in 53 patients with isolated mitral stenosis and regurgitation. The patients were divided into 3 groups; Group 1: the patients had conventional mitral valve replacement, Group 2: with preservation of posterior leaflet ventricular annular continuity (VAC) (33 patients), and Group 3: preservation of both anterior and posterior leaflet (8 patients). Operative technique was described for pure mitral regurgitation and mitral stenosis. There was one patient died within 30 days operatively in each group. In Group 1 the patient died for poor LV function, in Group 2, the patient died for postoperative GVHD, and in Group 3, the death caused by postoperative LV rupture. We have observed no late death. Minor thromboembolization in early stage were seen in 2 cases of Group 2 and there were no apparent correlation with operative technique. Postoperative cardiac catheterization data (Pulmonary Artery wedge pressure, C.O, LVEF, LVEDV1) showed no significant difference among these 3 groups. Segmental wall contraction in left ventriculography demonstrated good contraction in Group 2 and Group 3 compared with that of Group 1. Left ventricular contraction index with heart rate corrected mean Vcf (Vcfc) and left ventricular end-systolic wall stress (sigma es) relation using two dimensional cardiac echogram demonstrated almost normal range in the groups 2 and 3. These findings suggests that mitral valve replacement with preservation of ventricular annular continuity has beneficial effects on postoperative left ventricular function and requires to be further investigated.     

Reconstruction of a friable posterior mitral annulus after removing a calcified artificial ring using flipover technique of the anterior mitral leaflet

We report a new technique for reinforcement of a friable posterior mitral annulus using the anterior leaflet after removing a calcified artificial ring. A 72-year-old woman underwent mitral valve replacement for mitral stenosis and recurrence of regurgitation after mitral valve repair at 53 years of age. She had been on chronic hemodialysis for 20 years. The posterior mitral annulus became highly friable after débridement of the calcified artificial ring. The anterior mitral leaflet was detached from its annulus and transferred to the posterior annulus to cover the defect. The anterior leaflet was anchored to the posterior annulus by valve sutures, and mitral valve replacement was performed successfully. Postoperative ultrasonic cardiography revealed preservation of left ventricular function with no perivalvular leakage.