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.     

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.     

Rare early prosthesis obstruction after mitral valve replacement: a case report and literature review

ABSTRACT: As a dreadful complication after the mechanical heart valve replacement, prosthetic valve obstruction caused by pannus formation occurs increasingly with time. The authors here present a case of 42-year-old woman who was urgently admitted to hospital with acute heart failure symptoms due to the mechanical mitral valve failure only 3 months after surgery. Transthoracic and transesophageal echocardiography demonstrated that the bileaflet of the mitral prosthesis were completely immobilized with only a small transvalvular jet remained. During the reoperation, the reason of the prosthetic valve obstruction was attributed to the noncircular pannus ingrowth extending from the atrioventricular side. For a better understanding of the prosthetic valve dysfunction caused by pannus formation, the authors then compile a literature review to briefly discuss the status quo of the clinical characteristics of this uncommon complication.     

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.     

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.     

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.     

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.     

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.     

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.     

A surgical case for a Carbomedics stuck valve due to thrombotic pannus formation in the mitral position.

The patient was a 61-year-old female. She underwent mitral valve replacement (MVR) with a 27 mm Carbomedics valve and tricuspid valve annuloplasty using the DeVega method in September 1997. She has received anticoagulant therapy by aspirin and warfarin in a nearby hospital. Because of aggravating dyspnea and chest pain after an acute upper respiratory inflammation, she was transferred to our hospital on an emergency basis on April 14, 2003. Upon admission she went into cardiogenic shock and multiple-organ failure. Biolite carbon coating prevents adhesion of thrombus or pannus on the sewing cuff of Carbomedics valve, and there were few reports of Carbomedics valve dysfunction by pannus formation. But in this case cineradiography demonstrated the prosthetic valve was fixed in the closed position. We diagnosed acute heart failure due to a stuck valve in the mitral position, and redo MVR was performed in emergency. Thrombotic pannus extended from the sewing cuff and into the orifice on the inflow and outflow sides of the valve, and fixed both leaflets in a closed position. The postoperative course was uneventful, and she was discharged on the 20th postoperative day, and now anticoagulant therapy is managed in the outpatient clinic of our hospital. A combination of cineradiography and echocardiography provides a detailed diagnosis of asymptomatic valve dysfunction. Periodical examination by a prosthetic valve specialist is necessary in order to perform adequate anticoagulant therapy, echocardiography and cineradiography after prosthetic valve replacement.     

Simultaneous operation of WPW syndrome combined with mitral regurgitation caused by infective endocarditis

A case of WPW syndrome combined with mitral regurgitation caused by infective endocarditis underwent surgical division of accessory pathway and mitral valve replacement preserving posterior leaflet simultaneously. A 56-years old woman suffered atrial fibrillation with pseudo VT and cardiac failure caused by mitral regurgitation. Electro-physiological study (EPS) revealed accessory pathway in postero-lateral wall in left atrium and atrio-fascicular pathway like James bundle in AV node. ECHO cardiography showed mitral valve prolapse and severe regurgitation. Accessory pathway was divided surgically and deep freeze coagulation was followed. Perforation of anterior leaflet and chordal rupture of posterior leaflet caused by infective endocarditis were repaired by annuloplasty (Kay and McGoon method) at first, but regurgitation retained moderately. After re-clamping of aorta, mitral valve was replaced with prosthesis (SJM 29 mm) preserving posterior leaflet. Postoperative examination revealed division of accessory pathway and no regurgitation of mitral prosthesis.     

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.     

Late leaflet fracture and embolization of a Duromedics mitral prosthesis.

A case of leaflet fracture and embolization of a mitral prosthetic valve is described. A 54-year-old man had received mitral valve replacement with an Edwards-Duromedics 29M prosthetic valve, at 10 years ago. Emergency mitral valve replacement was performed because the patient had severe congestive left heart failure with severe acute mitral regurgitation caused by a fracture in one of the mitral valve leaflets. The leaflet, which was fractured into 2 pieces, was removed from the right common iliac artery at 3 months after valve replacement. Visual inspection revealed that the leaflet contained a midline fracture. The fracture originated within a cavitary erosion pit near the major radius of the leaflet. The patient recovered from acute renal failure, requiring hemodialysis for 80 days, and is currently without complaints. We have used a Duromedics mitral valve in 11 patients, from April 1987 to April 1988. No subsequent valve failure has occurred. The diagnosis, treatment and cause of a mechanical valve fracture are discussed.     

Episodic circulatory collapse caused by intermittent prosthetic aortic valve dysfunction

An 80-year-old woman with a 20-mm Medtronic Hall (tilting-disc) aortic prosthesis presented with episodes of chest pain associated with circulatory collapse and subsequent rapid spontaneous recovery. A computed tomography angiogram demonstrated no evidence of aortic dissection, pulmonary embolus, or coronary artery disease. A transthoracic echocardiogram demonstrated a well-functioning prosthetic aortic valve. After another inpatient episode, auscultation demonstrated an intermittent absence of the prosthetic second heart sound. A transesophageal echocardiography examination revealed that the aortic valve was intermittently sticking in the open position. During the emergency replacement, the existing valve was noted to have pannus and overlying thrombus, which are rare in this type of valve but can lead to dramatic circulatory collapse when present. This case demonstrates how a diagnosis of intermittent valve dysfunction can prove elusive. It is important, as part of the assessment of mechanical valves, to perform regular, careful auscultation and echocardiographic examination, with emphasis on recording in Doppler or M-mode through the valve at slow sweep speeds for a prolonged period in order to maximize the chance of diagnosing episodic valve dysfunction.     

Late results after mitral valve replacement with bileaflet mechanical prosthesis in children: evaluation of prosthesis-patient mismatch

BACKGROUND: Mechanical prosthesis is the choice of valve at the mitral position in children, although re-replacement of prostheses because of prosthesis-patient mismatch is almost inevitable when prostheses were implanted in small children. The methods to predict prosthesis-patient mismatch as a result of patients' somatic growth or pannus formation in children by noninvasive methods have not been well established. METHODS: Thirty-two children underwent mitral valve replacement with 37 bileaflet mechanical prostheses (26 St. Jude Medical prosthetic valves, and 11 CarboMedics prosthetic valves) and were followed up a mean of 6.8 years (maximum 18.3 years) with a complete follow-up rate of 94%. RESULTS: There were no operative deaths and 5 late deaths. Re-replacement of mitral valve because of prosthesis-patient mismatch was required in 5 patients. Freedom from valve-related events and re-replacement of mitral valve at 15 years were 32% +/- 23% and 54% +/- 18%, respectively. Actuarial survival rate was 63% +/- 19% at 15 years. Prosthetic valve orifice area index (manufactured geometric prosthetic valve area divided by patient's body surface area) was well correlated with maximum transprosthesis flow velocity estimated by Doppler echocardiography during follow-up, whereas valve orifice area index had no significant correlation with pulmonary artery wedge pressure assessed by cardiac catheterization. Maximum transprosthesis flow velocity had a significant correlation with pulmonary artery wedge pressure. CONCLUSIONS: Valve orifice area index itself was not a reliable index to predict prosthesis-patient mismatch. Maximum transprosthesis flow velocity was a useful index to predict pulmonary artery wedge. Invasive cardiac catheterization to determine re-replacement of the prosthesis should be considered when maximum transprosthesis flow velocity exceeds 270 cm/s.     

A case of aortic valve replacement with St. Jude Medical Regent valve (first implant in Japan).

The St. Jude Medical (SJM) Regent valve was developed as a new mechanical valve by improving the conventional SJM valve. The effective orifice area is wider than that of Hemodynamic Plus (HP) series. The efficacy of the new valve has been reported in Europe and the United States. On October 26, 2004, we first performed aortic valve replacement (AVR) with the SJM Regent valve for aortic valve stenosis in Japan. A 64-year-old female was admitted to our hospital with dyspnea on exertion. She was diagnosed with aortic valve stenosis. She underwent AVR with a 17 mm SJM Regent valve. According to the results of echocardiography conducted two months postoperatively, the peak pressure gradient of the prosthetic valve was 32.0 mmHg, the mean pressure gradient was 13.2 mmHg, and the effective orifice area index (EOAI) was 0.92 cm2/m2. Cinefluoroscopy showed the valve opening angle of 85 degrees indicating full opening. She was discharged 15 days after surgery without complications. As demonstrated by the present case, implantation of a 17 mm SJM Regent valve produced a satisfactory result reflected by lower pressure gradient and absence of patient-prosthetic mismatch. In the future, the new valve is expected to be the optimum mechanical valve for a narrow annulus.     

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.     

Optimal size of prostheses for functioning of the aortic prosthetic valve in aortic and mitral valve replacement with annular enlargement through Manouguian's technique

There is not yet agreement about the optimal size of the prostheses in aortic and mitral valve replacement with Manouguian's technique. In this technique, the aortic prosthetic valve can be pushed upon the mitral prosthesis which may cause dysfunction of the aortic prosthetic valve. The aim of this study was to clarify the size of the prostheses needed to avoid dysfunction of the aortic prosthetic valve. Three patients underwent aortic and mitral valve replacement through this procedure. Two of them had active aortic and mitral valve endocarditis. Aortomitral continuity involved with abscesses could be approached and completely excised using this technique. All patients survived the operation, but 1 of them suffered aortic mechanical valve dysfunction for the reason stated. Anatomical analysis of the geometrical relation of the 2 prosthetic valves suggests that the mitral annulus should be enlarged less than 25 mm to avoid dysfunction of the aortic prosthetic valve.     

Obstruction of the left ventricular outflow tract due to pannus formation after the implantation of a carbomedics aortic valve

Excessive pannus formation after implantation of a prosthetic valve is an infrequent but serious complication. A 69-year-old woman who had received a 19-mm CarboMedics aortic valve 11 years ago was readmitted to our hospital with dyspnea and chest oppression. Cineradiography did not show the restriction of valve movement. The aortic peak pressure gradient was calculated by Doppler echocardiography to be 104 mmHg. Based on the diagnosis of stenosis of the left ventricular outflow tract, the patient underwent reoperation. At reoperation, the pannus had formed circumferentially without disturbing the movement of the leaflet. A 19-mm St. Jude Medical Regent valve was implanted after enlargement of the aortic annulus. The patient’s postoperative course was uneventful. We report this characteristic finding of pannus formation after the implantation of a CarboMedics valve in the aortic position.     

Obstruction of the left ventricular outflow tract due to pannus formation after the implantation of a carbomedics aortic valve

Excessive pannus formation after implantation of a prosthetic valve is an infrequent but serious complication. A 69-year-old woman who had received a 19-mm CarboMedics aortic valve 11 years ago was readmitted to our hospital with dyspnea and chest oppression. Cineradiography did not show the restriction of valve movement. The aortic peak pressure gradient was calculated by Doppler echocardiography to be 104 mmHg. Based on the diagnosis of stenosis of the left ventricular outflow tract, the patient underwent reoperation. At reoperation, the pannus had formed circumferentially without disturbing the movement of the leaflet. A 19-mm St. Jude Medical Regent valve was implanted after enlargement of the aortic annulus. The patient’s postoperative course was uneventful. We report this characteristic finding of pannus formation after the implantation of a CarboMedics valve in the aortic position.