Perivalvular Leak Research Articles

Reoperation about recurrent heart valve disease in 221 cases

To retrospectively review the experience of reoperation after closed mitral commissurotomy, valvuloplasty, perivalvular leakage and dysfunction of bioprosthetic valve in 221 cases. Two hundred and twenty-one patients underwent heart valve reoperation from January 1998 to August 2005. Among them, 8 cases was emergency operation. The reasons of reoperation included 105 cases suffered from mitral valve restenosis after closed mitral commisurotomy, 37 cases suffered from valve lesion after mitral or aortic valvuloplasty, 29 cases suffered from perivalvular leakage after valve replacement. Eighteen cases suffered from bioprosthetic valve decline, 9 cases suffered from dysfunction of machine valve, 7 cases suffered from tricuspid insufficiency of Ebstein, 5 cases suffered from prosthetic valve endocarditis and 11 cases suffered from other valve disease. The re-operations were mitral valve replacement, mitral and aortic valve replacement, aortic valve replacement and tricuspid valve replacement. The interval from first operation to next operation was 1 - 21 years. The early-stage postoperative mortality was 8.6% (19/221). And the reasons were low cardiac output syndrome, arrhythmia, multiple organ dysfunction failure (MODF) and renal failure. Among these the emergency operative mortality was 3/8. And the mortality was 14.5% (9/62) in class IV of cardiac function (NYHA). The risk factors of reoperation about heart valve disease include emergency operation, low preoperative cardiac function, MODF, long time of cardiopulmonary bypass and aortic blocking. Therefore it is emphasized that mastering and treating the risk factors promptly, which could decrease the mortality and incidence of complication.

Implantation of a Modified Freestyle Valve With a Single Inflow Suture Line: Technical Patterns and Advantages

Subcoronary implantation of stentless valves may be a surgical challenge in the small aortic root. In addition, calcifications of coronary ostia may interfere with the procedure. We present a technique to trim a Freestyle stentlesss root (Medtronic Inc, Minneapolis, MN) and facilitate implantation with a single inflow suture line.

Mid-Term Results of Ross Procedure: Our Limited Experience

From February 1995 to February 2005, 30 patients underwent the Ross procedure with the root replacement technique. There were 20 males (66.7%) and 10 females (33.3%), aged 13 to 49 years. The diagnosis was aortic stenosis in 12 patients (40%), aortic regurgitation in 10 (33%), mixed stenosis and regurgitation in 6 (20%), prosthetic endocarditis with an aortic root abscess in 1 (3.3%), and a perivalvular leak in 1 (3.3%). There was no early or late death. Six patients (20%) suffered 7 significant operative complications. Over a median follow-up of 65 months (range, 4-114 months), there were 3 re-operations for autograft failure and 2 for homograft failure. No patient experienced a cerebrovascular accident, and all but one were free from endocarditis. Freedom from autograft failure was 94.1% +/- 5.7% at 5 years and 79.5% +/- 10.7% at 8 years, while freedom from homograft failure was 96.6% +/- 3.4% at 5 years and 88.5% +/- 8.3% at 8 years. Our midterm results show that good early and late survival can be obtained in young patients with aortic valve disease. Re-exploration for bleeding and late autograft failure are the main concerns of this challenging operation, especially early in the surgeon's learning-curve.

Invited commentary

Dr McCarthy discloses that he has a financial relationship with AVBG, LLC. Dr McCarthy discloses that he has a financial relationship with AVBG, LLC. Back to the future? Although highly successful, aortic valve replacement still has a host of problems that need to be managed. These problems include the following: ascending aortic calcification that can embolize or complicate aortic cross clamping or aortotomy closure; a small aortic annulus that may require patch enlargement (a more complex operation with higher risks), or the possibility for patient prosthesis mismatch; possible peri-valvular leak depending on the quality of the aortic annulus and the experience of the cardiac surgeon; heart block; fibrosis and calcification from radiation heart disease; and various problems in patients with patent coronary bypass grafts such as managing proximals attached near the aortotomy, avoiding a left internal mammary artery graft that may be in the midline, and obtaining adequate myocardial protection. Oftentimes primary aortic valve replacement is a low-risk operation. However, elderly patients with comorbidities that lead to high operative risk stimulated the development of percutaneous aortic valve replacement. Just as the advent of stenting pushed surgeons to consider more creative ways to perform coronary artery bypass, the advent of percutaneous valve techniques has stimulated surgeons to consider alternative approaches to conventional aortic valve replacement. The advantages of the aortic valve bypass as described in this article are to avoid the problems of conventional aortic valve replacement in high-risk patients. A strong advantage over percutaneous aortic valve approaches is the ability to use a known commercially available prosthetic valve with a strong track record for durability. Ideal candidates for this type of approach could include patients with ascending aortic calcification, patients who require complex reoperations, and patients with a small annulus. With new strategies and new technologies this can become a very attractive alternative for a significant percentage of patients undergoing isolated aortic valve replacement (i.e., 5.8% in Gammie and colleagues’ [1Gammie J.S. Brown J.W. Brown J.M. et al.Aortic valve bypass for the high-risk patient with aortic stenosis.Ann Thorac Surg. 2006; 81: 1605-1611Abstract Full Text Full Text PDF PubMed Scopus (48) Google Scholar] experience). However, current state of the art is to modify existing conduits and valves adapted to fit this very different situation. The potential problems with the aortic valve bypass approach include pseudoaneurysm as described in their article, bleeding due to lack of control of the left ventricular (LV) apex, difficulty with the aortic anastomosis in the descending aorta due to extensive calcification of the descending aorta, kinking of the conduit because it is either too long or too short, and theoretical dislodgement of an LV apical thrombus that may not be visible by preoperative or intraoperative imaging. Should cardiopulmonary bypass be required, then it would typically employ retrograde perfusion, either from the femoral artery or a side graft from the aortic graft as described in this article, with a risk of embolization. Theoretical problems may include the nonphysiologic flow from the LV apex to the descending aorta. However, surgeons have grown used to a very successful operation that does not provide physiologic flow in coronary artery bypass. In the same way, bypassing the native aortic valve provides a clever way to work around difficult situations in some of our elderly and otherwise sick patients. With more than a 20-year history in patients, this would seem to be a strategy that has long-term durability and is not something that one would expect to see reproduced with any of the percutaneous aortic valve technologies. For this reason, surgeons should be interested in resurrecting this technique and looking forward to ways to simplify the operation and bring this to a more routine clinical care.

Continuous-Suture Technique in Aortic Valve Replacement

From April 2000 to April 2003 total 103 patients underwent aortic valve replacement and some concomitant cardiac procedures including mitral valve replacement in our hospital. According to the suture technique used in aortic valve replacement, the patients were divided into two groups: group A, 42 patients, the continuous suture technique with some modifications was used; group B, 61 patients, the conventional interrupted suture technique was used. There were no statistical differences between the two groups in age, sex, bodyweight, valve lesion, concomitant cardiac procedure and early mortality. But there were significant differences ([<0.001 approximately 0.012) in aortic cross-clamp time (AOCT) and cardiopulmonary bypass time (CPBT) between the two groups with less time for the group A patients. During a follow-up from 1 to 35 months, in group B, one patient developed perivalvular leak. The incidence of perivalvular leak was 1.7% (1/59). Three patients developed prosthetic bacterial endocarditis, the incidence of which was 5.0% (3/59). All the patients in group A recovered satisfactorily without suture technique or prosthesis associated complications. The modified technique was introduced and illustrated with diagrams, and the reasons for the advantages of the technique over the conventional interrupted suture technique were discussed.

The CarboMedics prosthetic heart valve: experience with 180 implants

At Jichi Medical School Hospital, three types of mechanical prosthetic valves (CarboMedics, Omnicarbon, Bicarbon) were used without randomization from 1991 to 2000. A retrospective study of valve replacements done between June 1991 and November 2000 utilizing 180 CarboMedics valves in 145 patients who had not previously undergone prosthetic valve replacement or aortic root and/or arch replacement was conducted to evaluate midterm patient outcomes to assess the future continuous use of CarboMedics valves. Women made up 47.6% of the patients and the mean age was 57.5 years (range 12-80 years). Preoperative New York Heart Association functional class was III or IV in 92.4% (134/145) of patients. Mean follow-up of 4.5 years (range 0-10.0 years) was 95.9% complete, with a total of 628 patient-years (PY). Early (within 30 postoperative days) mortality was 5.5% (8 of 145): 3 from hemorrhage, 3 from nonvalve-related heart failure, 1 from infection, and 1 from arrhythmia. There were 16 late deaths (2.54%/PY): 1 from hemorrhage, 4 from unknown causes/sudden death, 4 from nonvalve-related heart failure, and 7 from other noncardiac causes. A total of 121 patients (83.0%) were alive at the last follow-up, done in November 2000. The linearized death rate was 3.82%/year (including 1.11%/year for valve-related deaths). Linearized death rates from various causes were: bleeding, 0.96%/year; thromboembolism, 1.11%/year; thrombosis, 0.39%/year; perivalvular leak, 0.96%/year; endocarditis, 0%/year; hemolysis, 0%/year; and reoperation, 0.63%/year. No structural valve failure was observed. Comparative early mortality rates of valve replacement without aortic root replacement or arch replacement, excluding repeat valve replacement operations, in our institute, were 3.5% (12/307) for all valve types used contemporaneously, 2.6% (2/76) for Omnicarbon valves, and 2.3% (2/86) for Bicarbon valves. Although the CarboMedics valve had a rather high mortality rate of 5.5% (8/145) compared with the total early mortality rate of 3.5%, the low incidence of valve-related complications might support the continued use of the CarboMedics valve for valve replacement.

NextStitch: double-stranded suture chain, a tool to optimize approximation of sutures in valve surgery with echocardiographic correlation.

Suture technique for valve replacement surgery has often focused on decreasing the soft tissue injury that leads to pseudoaneurysm formation and associated latent infection. There is universal recognition that precise suture placement is essential for avoiding adverse sequelae while allowing flexibility during the implantation of the prosthesis. The use of a continuous chain of linked horizontal mattress sutures (NextStitch) has allowed maximal precision in the approximation of sutures within the valve annulus. The product was used in a series of consecutive mitral and aortic valve replacements, and typical echocardiographic images from each type of implantation are presented. Postoperative echocardiography images revealed that no perivalvular leaks occurred and that NextStitch did not obscure detailed interrogation or assessment of the valve prosthesis.

133Xenon ventilation scintigraphy applied to bronchoscopic lung volume reduction techniques for emphysema: relevance of interlobar collaterals

133Xenon ventilation scintigraphy and (99m)Tc-MAA perfusion scintigraphy can be used to assess dynamic ventilation patterns in patients with severe emphysema. To describe the scintigraphic features of attempted bronchoscopic lung volume reduction (BLVR), exploring mechanisms that might explain the unexpected lack of postoperative atelectasis. Five patients with heterogenous severe upper lobe emphysema were evaluated with 133Xenon ventilation and (99m)Tc-MAA perfusion scintigraphy, chest radiography, bronchoscopy and high resolution computed tomography before and up to 1 month after endoscopic placement of bronchial prostheses (BLVR). Ex vivo assessment of the lungs of two further patients with severe upper lobe emphysema was performed. No significant subsegmental or lobar collapse was evident on post-procedure chest radiography or high resolution computed tomography, despite bronchoscopic confirmation of adequate position and functioning of prostheses. 133Xenon ventilation scintigraphy confirms significantly decreased upper lobe wash-in (P < 0.023), unchanged lower lobe wash-in and significantly increased lower lobe wash-out rates (P < 0.005) after BLVR. Significant redistribution of perfusion to the lower lobes occurred after BLVR (P < 0.025). Ex vivo experiments on explanted emphysematous lungs demonstrated that these findings could best be explained by collateral interlobar ventilation, which was calculated in one specimen to be as high as 15% of total lower lobe ventilation. Peri-valvular leak is a much less likely possibility. 133Xenon ventilation scintigraphy indicated the presence of significant interlobar collateral ventilation in patients with severe emphysema that may have major relevance to these novel alternative techniques to lung volume reduction surgery. 133Xenon scintigraphy can be used in the evaluation of severe emphysema before and after novel therapeutic interventions.

Ablation of Permanent Atrial Fibrillation in Cardiac Surgery. Short-Term and Mid-Term Results

Surgical ablation of atrial fibrillation is currently a simple procedure that can be done during cardiac surgery in most patients. A number of different energy sources now available allow to easily create ablation lines in the atria. We describe our experience during the previous three years. In 93 patients with cardiac problems treated with surgery and permanent atrial fibrillation (longer than 3 months), surgical ablation of the arrhythmia was done at the same time. Mean duration of the atrial fibrillation was 6 years (range 0.3 to 24 years). Mean (SD) preoperative size of the atrium as measured echocardiographically was 51.7 (8.8) mm (range 35 to 77 mm). Five patients died in the hospital (5.3% in-hospital mortality). After a mean follow-up of 10 months, 83.8% of the patients had recovered and maintained sinus rhythm, and 16.1% of the patients remained in atrial fibrillation. A permanent pacemaker was implanted in 3 of these patients. Among the 82 patients followed for more than 6 months, the prevalence of sinus rhythm was 84.1%. Echocardiographically documented contractility in both atria was observed in 50% of the patients. Major complications related to the ablation procedure occurred in 3.5% of the patients, and consisted of a perivalvular leak 2 months after surgery, a circumflex artery spasm, and an atrio-esophageal fistula. Surgical ablation of permanent atrial fibrillation is a simple procedure associated with low morbidity and mortality, and with recovery of sinus rhythm in most patients. The main problem with the procedure is the incidence of early postoperative arrhythmias.

Impact of intraoperative transesophageal echocardiography in patients undergoing valve replacement

Background The role of intraoperative transesophageal echocardiography (IOTEE) in valve replacement surgery is not well established. The aim of this study was to explore the impact of immediate postpump IOTEE in valve replacement surgery at a single tertiary medical center. Methods The departmental database was screened for valve replacement operations (mechanical or bioprosthetic valves) performed during a 55-month period that were succeeded by immediate postpump IOTEE. Data was gathered regarding the impact of IOTEE on the immediate postoperative course. Results The study group included 417 patients (44.8% male, 55.2% female, age 65.2 ± 13.9 years). Prepump IOTEE was performed in 352 patients (84.4%). A single valve was replaced in 336 patients (80.6%) and two or more valves were replaced in 81 patients (19.4%). Overall 501 valves were inserted: mitral, 237 (131 mechanical, 106 biological); aortic, 221 (89 mechanical, 132 biological); tricuspid, 43 (2 mechanical, 41 biological). Unexpected pathologic echocardiographic findings on postpump IOTEE necessitated immediate surgical correction in 15 patients (3.6%): perivalvular leak in 8 patients (4 mitral, 4 aortic), immobilized leaflet in 4 patients (3 mitral, 1 tricuspid), coronary obstruction by an aortic bioprosthesis in 2 patients, and incompetent xenograft in 1 patient. Prolonged removal of air was necessary in 45 patients (10.8%). In 47 patients (11.3%) the postpump IOTEE contributed to the evaluation of difficult weaning from the bypass pump and to its appropriate therapeutic management (volume expansion, inotropic agents, vasodilators, or mechanical assistance). Conclusions Immediate postpump IOTEE is an important diagnostic and therapeutic role in valve replacement surgery and should be widely implemented.

The potential for bronchoscopic lung volume reduction using bronchial prostheses. A pilot study

The potential for bronchoscopic lung volume reduction using bronchial prostheses. A pilot study

Hemolysis after mitral valve repair: mechanisms and treatment

Background The objectives of this study were to determine the mechanisms of hemolysis after mitral valve repair and to determine outcomes after surgical treatment (mitral replacement or re-repair). Methods Between 1981 and 2002, 32 patients (mean age, 58 years) presented with hemolytic anemia after mitral valve repair for degenerative, rheumatic, or ischemic mitral regurgitation (MR). Three types of annuloplasty were used at the initial mitral valve repair: Cosgrove-Edwards, Carpentier-Edwards, and bovine pericardial (Perigard). The diagnosis and the mechanisms of hemolysis were investigated with laboratory testing and echocardiography. Results Median interval from initial mitral valve surgery to diagnosis of hemolysis was 3 months (range, 1 week to 4 years). At presentation, mean hematocrit was 27.5% ± 4.9% and 22 patients (69%) required transfusion. Echocardiographic findings varied. Twenty-four patients (77%) had grade 3 or 4 MR. Mitral regurgitant jet types included fragmentation (11 patients, 34%), acceleration (10, 31%), slow deceleration (5, 16%), collision (4, 13%), and free jet (2, 6%). Mitral valve replacement was performed in 28 patients, mitral valve re-repair in 3, and 1 patient did not undergo reoperation. At reoperation the mitral valve repair was physically intact in 25 of 31 patients (81%). There were 2 hospital deaths in patients having reoperation (6%). Actuarial survival was 95% at 1 year and 85% at 5 years. In 1 patient recurrent mechanical hemolysis developed caused by a perivalvular leak after mitral valve replacement. Conclusions Hemolysis is a mode of failure of mitral valve repair. Patients with hemolysis generally present within 3 months of mitral valve repair. Although echocardiographic features varied, most patients had high-grade MR and regurgitant jets that fragmented or accelerated. Mitral valve replacement yields favorable outcomes for patients with hemolysis after mitral valve repair.

Preclinical assessment of a trileaflet mechanical valve in the mitral position in a calf model

Background The bileaflet valve is currently the mechanical replacement valve of choice. Though durable, it does not closely mimic native valve hemodynamics and remains potentially thrombogenic. Methods Prototype trileaflet valves (T1 and T2) were implanted in the mitral position in calves. Group I calves received either a T1 valve (n = 12) or a control bileaflet valve (n = 5); Group II, either a T2 valve (n = 7) or a control bileaflet valve (n = 5). Valve function, perivalvular leakage, and transvalvular pressure gradients were evaluated. Also, long-term prototype leaflet wear was evaluated in vivo in one Group I calf (502 days) and two Group II calves (385 and 366 days). Calves were euthanized and necropsied at study termination, and major organs weighed and examined. Results Valve function was excellent and hematologic parameters remained normal in all calves that survived to study termination. Mean peak transvalvular pressure gradients were 10 ± 7 mm Hg for T1 valves, 6 ± 3 mm Hg for T2 valves, and 12 ± 4 mm Hg for bileaflet control valves. Clinically insignificant valvular regurgitation was observed in both prototypes. Explanted valves showed no thrombus-impaired leaflet motion, except in two T1-fitted calves and one T2-fitted calf. Major organs showed no evidence of clinically significant thromboembolic events. There were no other significant differences between the results of experimental and control groups. Conclusions Prototype trileaflet valves performed safely and effectively in the mitral position in calves, even without long-term anticoagulation. This warrants their evaluation as an equivalent alternative to bileaflet valves.

Chronic mitral regurgitation secondary to a perivalvular leak from remote trauma

We report a rare case of mitral regurgitation as a result of perivalvular leak in a 49-year-old man with a history of blunt trauma. He presented with a 2-month history of progressive exertional dyspnea, angina, and heart failure. Preoperative transesophageal echocardiography demonstrated severe mitral regurgitation as a result of a perivalvular leak of the mitral valve that was not evident on transthoracic echocardiography and cardiac catheterization.

The challenge pays off: Early enhanced nutritional intake for VLBW small-for-gestation neonates improves long-term outcome

The challenge pays off: Early enhanced nutritional intake for VLBW small-for-gestation neonates improves long-term outcome

Unexpected durability of smeloff-cutter aortic ball valve prosthesis

We report a case in which replacement of a Smeloff-Cutter aortic ball prosthesis was required 28 years after initial implantation. A 57-year-old woman underwent aortic valve replacement with a 21-mm Smeloff-Cutter ball prosthesis and open mitral commissurotomy for aortic stenosis, aortic regurgitation, and mitral stenosis in 1973. Severe aortic regurgitation occurred in April 2001, and aortic valve reoperation combined with mitral valve replacement was successfully performed. The patient’s aortic ball valve was nearly intact with perivalvular leakage probably causing the aortic regurgitation. Our experience documents longer durability for the Smeloff-Cutter prosthesis than has been reported to date.

A different kind of aneurysm

A 43-YEAR-OLD white woman was admitted with a preoperative diagnosis of a sinus of Valsalva aneurysm. In 1979, 22 years before this admission, she had been diagnosed with Staphylococcus aureus endocarditis and underwent aortic valve replacement with a Bjork-Shiley mechanical valve. In 1998, 19 years later, she developed hemodynamically significant aortic regurgitation. At that time, a transesophageal echocardiogram showed the presence of a large perivalvular leak and a large noncoronary sinus of Valsalva aneurysm.

Aortic valve replacement in patients age 70 years and older: early and late results.

This retrospective analysis was performed to determine the early and late outcome in patients 70 years and older undergoing aortic valve replacement (AVR). From October 1994 to May 2001, 49 patients (24 men and 25 women, age 70 to 88 years [mean 74 +/- 4.6 years]) underwent primary AVR with or without concomitant procedures. Twenty-one received mechanical valves and 28 bioprostheses. Age was different between both groups: 72 +/- 2.3 years (mechanical) and 76 +/- 5.1 years (bioprosthetic) (p = 0.0005). Aortic stenosis was present in 25 patients (51%). Follow-up was 100% complete at a mean follow-up of 2.9 years (range 0.3-6.5 years). Overall hospital mortality was 4.1% (2/49). There were no postoperative complications in 24% of patients. Postoperative hospital stay or hospital survival was 27 +/- 13 days. Survival at 3 and 5 years was 89 +/- 5% and 80 +/- 7%, respectively. Three late deaths were due to noncardiac causes and 1 each had a cardiac or valve-related cause (thromboembolism). Other valve-related complications such as anticoagulant-related hemorrhage, perivalvular leak, endocarditis, prosthetic valve failure, and reoperation were not noted in any of the 49 patients. The actuarial survival curve was similar in each group of bioprosthetic versus mechanical and septuagenarians versus octogenarians. Under the selection criteria for AVR currently applied in our hospital, geriatric patients showed a satisfactory early outcome and medium-term survival benefit.

Eight-year results of aortic root replacement with the freestyle stentless porcine aortic root bioprosthesis

Background. Stentless porcine aortic valves offer several advantages over traditional valves. Among these are superior hemodynamics, laminar flow patterns, lack of need for anticoagulation, and perhaps improved durability. Methods. One hundred four patients were operated on from September 17, 1992, to October 31, 1997, as part of a multicenter worldwide investigation of the Medtronic Freestyle stentless porcine bioprosthesis. All patients received a total aortic root replacement. The patients were evaluated postoperatively at discharge, at 3 to 6 months, and yearly by clinical examination and color flow Doppler echocardiography. Results. Operative mortality was 3.9%. No patient experienced structural valve deterioration, nonstructural deterioration, perivalvular leak, or unacceptable hemodynamic performance. At 8 years, survival was 59.8%. Freedom from thromboembolic complications was 83.3%. Freedom from postoperative endocarditis was 96.9%. Freedom from reoperation was 100%. Mean systolic gradients did not change over the time period studied. They were 6.4 ± 3.8 mm Hg at 1 year and 6.7 ± 2.6 mm Hg at 8 years. Correspondingly, effective orifice area was 1.9 ± 0.7 cm 2 at 1 year and 1.8 ± 0.8 cm 2 at 8 years. The incidence of any aortic insufficiency also did not change over the length of follow-up. At 1 year, 98% of patients had no or trivial aortic insufficiency and 2% had mild aortic insufficiency. At 8 years, 100% of patients evaluated were free of any aortic insufficiency. Conclusions. The Medtronic Freestyle aortic root bioprosthesis can be used safely to replace the aortic root or aortic valve for aortic valve and aortic root pathology. Total root replacement allows optimal hemodynamic performance with no significant aortic regurgitation. Results up to 8 years show excellent survival and no signs of degeneration. Further follow-up is still needed to determine valve durability.

Acute Mitral Regurgitation Due to a Torn Porcine Bioprosthetic Cusp

A 46-year-old man presented with a 48-hour history of fevers, sweats, and dyspnea. He had bacterial endocarditis of the native mitral valve 12 years earlier with subsequent mitral valve replacement (MVR) with a Hancock II porcine valve (Medtronic Inc). Examination revealed a Grade 3/6 holosystolic murmur at the apex radiating into the axilla with crackles heard halfway up both lung fields. A diagnosis of infective endocarditis with acute mitral regurgitation (MR) was made and serial blood cultures drawn. Transesophageal echocardiogram (TEE) revealed severe MR (Figure 1). The MR was transvalvular with no perivalvular leak.1–3⇓⇓ A large mobile linear echodense mass (length=2.0 cm) was seen in the left ventricle and this prolapsed across the valve into the left atrium (LA, Figure 2 through 4⇓⇓) along with partial prolapse of one of the leaflets of the …