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.     

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.     

Impact of implant technique following freestyle stentless aortic valve replacement

BACKGROUND: Stentless aortic bioprostheses have excellent hemodynamics and clinical outcomes. The purpose of the present study was to determine whether implant technique of the Freestyle aortic root bioprosthesis impacts clinical outcomes or hemodynamic performance. METHODS: The long-term multicenter study of the Freestyle stentless aortic bioprosthesis includes 500 consecutive patients implanted using the subcoronary and 162 using the full root technique. Clinical outcomes and echocardiographic hemodynamics were compared through 5 years. RESULTS: There were no differences between groups in time to death, valve-related death, or reoperation. The incidence of operative death was higher in the full root than in the subcoronary group (odds ratio 3.97, p = 0.001). Patients in the subcoronary group were more likely to have New York Heart Association functional class III or IV symptoms at 1 year (1.7% versus 0%, p = 0.04) and 5 years postoperatively (4.4% versus 0%, p = 0.02). Mean gradient was lower (p = 0.0004) and effective orifice area larger (p = 0.04) in the full root group. Left ventricular mass index decreased in both groups. The preponderance of patients in both groups had no or trivial aortic regurgitation through 5 years. CONCLUSIONS: Full root implantation of the Freestyle stentless aortic bioprosthesis was associated with higher operative mortality, but somewhat better hemodynamics, functional class, and freedom from aortic regurgitation. Higher operative mortality argues against the empiric replacement of the ascending aorta in the absence of aortic root pathology. In appropriately selected patients, both implant techniques are viable alternatives for valve implantation.     

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.     

Redo-operation for the cusp perforation 5 years after aortic valve replacement with stentless bioprosthesis; report of a case

A 31-year-old male presented with increase of aortic valve regurgitation 5 years after implantation of Prima Plus Stentless bioprosthesis in a bicuspid aortic valve. He underwent redo aortic valve replacement with a mechanical valve concomitant with replacement of the ascending aorta. Pathological examination of the explanted stentless valve presented no inflammatory cell infiltration. The prosthetic valve regurgitation was considered to be due to small injury at the 1st operation.     

Aortic regurgitation due to perforation of the right coronary cusp 10 years after implantation of a freestyle stentless bioprosthesis

Valve deterioration following aortic valve replacement using the Freestyle stentless bioprosthesis is related to cusp tear, operative injury, or infection. We report a patient with aortic regurgitation due to perforation of the right coronary cusp 10 years after implantation of a Freestyle stentless bioprosthesis in the absence of endocarditis.     

Aortic valve replacement with a freestyle stentless valve using the modified subcoronary technique and hemiarch replacement for bicuspid aortic valve and ascending aortic aneurysma; report of a case

An association between bicuspid aortic valve disease and ascending aortic aneurysma has long been recognized. Root replacement with a composite valve graft for such disease is a well-established technique. But it may involve serious technical difficulties, and may be a more time-consuming procedure than separate valve replacement and graft replacement. We performed an aortic valve replacement with Freestyle stentless valve using the modified subcoronary technique and hemiarch replacement for a 72-year-old man with severe aortic stenosis and ascending aortic aneurysma. Angiographic studies after surgery showed no residual aortic regurgitation (AR) and no deformity of aorta. This technique is an acceptable option for an aortic disease and ascending aneurysma in elderly patients.     

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.     

Aortic valve replacement with a stentless porcine aortic root bioprosthesis

From April, 1999 to November, 1999, 8 patients underwent the aortic valve replacement using Medtronic Freestyle aortic root bioprosthesis. Mean age was 67.8 years old. Aortic valve etiology was as follows, AS: 1 case, AR: 2 cases, ASR: 3 cases, IE: 1 case, mechanical valve malfunction due to subvalvular pannus: 1 case. The implanted valve size was 25: 2 cases, 23: 3 cases, 21: 1 cases, 19: 2 cases. Surgical technique was subcoronary: 7 cases, full-root: 1 case. Post-op 2D-echo revealed tribial aortic valve incompetence in two cases because of size discrepancy between the aortic annulus and the ascending aorta. Pacemaker implantation was needed in 1 case because of the complete A-V block. In comparison with 5 cases of aortic valve replacement with Hancock II performed in same period, there were no significant differences about the implanted valve size and mean systolic pressure gradient, but the effective orifice area in Freestyle cases was significantly larger than Hancock II cases.     

Transapical combined transcatheter aortic valve-in-valve implant and ascending aorta endovascular repair

We report the case of a 64-year-old patient who previously had an aortic valve replacement with a stentless aortic valve and an ascending aorta replacement for a DeBakey type II aortic dissection. The patient was referred to us for symptomatic aortic regurgitation related to bioprosthesis degeneration and a pseudoaneurysm at the distal anastomotic site of the vascular graft. Due to the presence of several comorbidities, the patient had a combined transapical transcatheter aortic valve-in-valve implant and an ascending aorta endovascular repair.     

Aortic valve/root replacement using a stentless bioprosthesis (Medtronic Freestyle valve)

BACKGROUND: The purpose of the study is to assess the clinical and hemodynamic performance of aortic valve replacement (AVR) with the Freestyle bioprosthesis. METHODS: Twenty-one patients received AVR with a Freestyle aortic root bio-prosthesis between May 1998 and October 1999. Eighteen patients underwent AVR with subcoronary method and three patients with aortic root (full root) method. Patients were evaluated postoperatively at discharge by clinical examination and color Doppler echocardiography. RESULTS: There was one death due to multi-organ failure. No patients experienced valve deterioration, paravalvular leak, unacceptable hemodynamic performance, nor thromboembolic event. Excellent function is demonstrated by very low gradient (mean gradient 7.2 +/- 4.7 mmHg) through aortic valve and no significant aortic regurgitation (none: 11, trivial/mild: 10). All patients had been in New York Heart Association Functional Class III and IV preoperatively, and after surgery, 17 patients were in Class I, and 3 were in Class II. CONCLUSION: The Freestyle bioprosthesis has good clinical and hemodynamic performance without Coumadin. Further follow-up is required to evaluated valve durability.     

Percutaneous valve‐in‐valve procedure and simultaneous paravalvular leak closure

Concern for early degeneration limits the use of bioprosthetic heart valves. A 77‐year‐old man who underwent surgical aortic valve replacement at age 70 for severe aortic stenosis (AoS) presented with premature bioprosthesis degeneration and AoS recurrence. Transthoracic echocardiography demonstrated severe AoS and aortic regurgitation, a 30% ejection fraction, and pulmonary hypertension. Transesophageal echocardiography revealed that the aortic regurgitation was due to a 5‐mm paravalvular leak (PVL). A high EuroScoreII excluded surgical treatment. Simultaneous transcatheter aortic valve replacement and PVL closure with an Occlutech PLD Square 5 Twist PVL closure device were performed with good results and improved clinical status.     

Medtronic Freestyle Aortic Root Bioprosthesis: Implant Techniques

BACKGROUND: The Medtronic Freestyle aortic root bioprosthesis is a complete porcine aortic root to allow implantation (1) as a subcoronary valve replacement by removing graft sinus aorta, (2) as a cylinder with the sinotubular junction intact within the aorta (root inclusion), or (3) as a complete aortic root replacement. The choice among the three implant techniques depends on surgeon preference or upon the pathology encountered. The advantages and differences among the three implant techniques are examined. METHODS: The Medtronic Freestyle bioprosthesis was implanted in 1163 patients in a Food and Drug administration (FDA) clinical trial between August 1992 and October 1997. There were 21 centers in the international trial using a single data repository. Clinical data was collected prior to and at operation, at 3 to 6 months and annually. The data were compiled and statistical analysis performed at the data center. RESULTS: Patients having subcoronary valve implants were older (80% > 65 years) and aortic occlusion time was about 20 minutes less than the other methods. Patients having aortic root replacement presented with more aortic valve insufficiency (20%). Pathology of the aortic root and ascending aorta requiring repair was 26%, and larger (27 mm) valves were used in 40% of patients. Risk of operation was lowest (5.0%) with subcoronary valve implants and highest (11.7%) with root replacement technique. Thromboembolism was higher, early and late, with root inclusion (3.0, 3.9%/patient per year) and root replacement (3.2, 3.0%/patient per year) than for subcoronary implants (1.8, 1.6%/patient per year). There were more patients taking warfarin at the 4-year point with root inclusion (20%) or root replacement techniques (24%) than among patients having subcoronary implants (14%). Explants of the valve occurred in 2% of patients, none of whom had aortic root replacement. CONCLUSIONS: The Medtronic Freestyle bioprosthesis is an effective and versatile device for replacement of the aortic valve. It offers implant techniques that can treat the aortic root pathology encountered at surgery and allows the operation to proceed according to surgeon preference.     

Management of anomalous right coronary arteries encountered during aortic valve surgery.

We experienced three cases with anomalous right coronary arteries during aortic valve surgery. By rotating a Freestyle bioprosthesis by a subcoronary technique, the anomalous artery was secured in one patient. The anomalous artery was injured during the routine aortotomy incision in another patient; a saphenous vein graft was interposed between the ascending aorta and the separated artery. In the third patient, a subannular prosthetic valve was chosen to avoid obstructing the anomalous orifice.     

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.     

A technique of aortic annulus enlargement with a Freestyle stentless bioprosthesis

We describe our surgical technique to manage a small aortic annulus during aortic valve replacement. Starting with the posterior annular enlargement incision described by Manouguian, a stentless porcine aortic root, with excision of the left and right porcine coronary segments and conservation of the mural wall (Freestyle MS design, Medtronic, Minneapolis, MN ), was used. The Freestyle bioprosthesis enlarges the aortic annulus using a direct suture of the valve on the enlarged annulus, and the aorta is closed by a direct suture of the mural wall of the bioprosthesis. Therefore, the aortic annulus enlargement is made only using the aortic bioprosthesis, without other material.     

Primary tissue failure of the freestyle stentless aortic root bioprosthesis

We present a case of early tissue failure of the Medtronic Freestyle stentless bioprosthesis used in the aortic position which led to reoperation 27 months after implantation. Almost one half of the left coronary cusp of the prosthetic valve had torn away along the annulus. The tear started from the left-non coronary commissure and reached the midpoint of the base of the left coronary cusp. The prosthetic valve was easily excised and replaced with a new mechanical valve. There was no sign of calcification or vegetation in the excised valve. The cause of the valve dysfunction was thought to be primary tissue failure. Long-term function of the Freestyle stentless valve should be carefully followed up.     

Primary tissue failure of the freestyle stentless aortic root bioprosthesis

We present a case of early tissue failure of the Medtronic Freestyle stentless bioprosthesis used in the aortic position which led to reoperation 27 months after implantation. Almost one half of the left coronary cusp of the prosthetic valve had torn away along the annulus. The tear started from the left-non coronary commissure and reached the midpoint of the base of the left coronary cusp. The prosthetic valve was easily excised and replaced with a new mechanical valve. There was no sign of calcification or vegetation in the excised valve. The cause of the valve dysfunction was thought to be primary tissue failure. Long-term function of the Freestyle stentless valve should be carefully followed up.     

Aortic root replacement with a freestyle stentless valve for aortitis syndrome with ascending aortic aneurysm and aortic regurgitation.

A 47-year-old woman who had been diagnosed as having aortitis syndrome underwent aortic root replacement for an ascending aortic aneurysm and aortic regurgitation. Because the patient has been treated with steroids for more than 20 years, a Freestyle stentless valve was used to avoid the risk of valve detachment. There were no complications observed during the postoperative course. Although long-term follow-up will be necessary to observe the valve durability, the Freestyle stentless valve seems to be useful for aortic root replacement in patients at high risk of valve detachment due to aortitis syndrome.     

Stentless aortic root bioprosthesis (freestyle) to patients of bicuspid aortic valve with abnormal positioning of the coronary ostia]

Stentless aortic root bioprosthesis (Freestyle) was implanted to two patients of bicuspid aortic valve stenosis with anatomically abnormal positioning of the coronary ostia. In a patient of LR type bicuspid valve, the left coronary artery was located at 180 degrees against the right coronary ostium. To match the Valsalva sinus of the patient with bioprosthesis, the left half of the native annulus, 23 mm in the diameter, was plicated corresponding to the one third of the Freestyle inflow, 21 mm in the diameter. In the other patient of AP type bicuspid valve, both coronary ostia were closely positioned at 90 degrees. To keep both ostia in the sinus of bioprosthesis, careful trimming and suturing were required in the narrow part of both ostia. Their postoperative courses were uneventful and no regurgitation has been observed in either case.