Redo Aortic Valve Replacement Research Articles

Minimally invasive redo aortic valve replacement with a sutureless valve implant.

Reoperations for a dysfunctional mechanical aortic valve prosthesis are usually performed with a repeat sternotomy. Reopening the chest may be associated with a heart structure tear, bleeding, excessive transfusion, and a possible unfavorable outcome. Experience performing a redo aortic valve replacement with a minimally invasive approach and avoiding lysis of the pericardial adhesions is growing. We describe a redo aortic valve replacement procedure performed because of subvalvular pannus formation in a patient with a mechanical prosthesis. A partial J-shaped hemisternotomy at the 3rd intercostal space was performed; the ascending aorta was exposed and the valve was replaced with a sutureless bioprosthesis. The video tutorial shows the surgical approach, cardiopulmonary bypass solutions, and sutureless valve deployment.

A Y Incision and Rectangular Patch to Enlarge the Aortic Annulus by Three Valve Sizes

For a fifth-time redo aortic valve replacement, a Y incision was made through the left-noncommissure post into the aortomitral curtain above the mitral annulus, undermining the aortic annulus below the nadirs of left coronary and noncoronary cusps without violating the left atrium or mitral valve. A rectangular Hemashield (Maquet Cardiovascular, San Jose, CA) patch was used to extensively enlarge the aortomitral curtain. The aortic annulus was increased from 21 mm to 27 mm for a mechanical aortic valve replacement. The patient was discharged without blood transfusion or any complications. Our enlargement technique was simple and effective to enlarge the aortic annulus for mechanical aortic valve replacement.

Effectiveness of Multidetector Computed Tomography in Prosthetic Valve Endocarditis

Background: Redo aortic valve replacement for prosthetic valve endocarditis is a challenge for surgeons. Echocardiography is occasionally not an effective modality for the detection of infectious signs in prosthetic valve endocarditis. Case presentation: Herein, we report the case of a patient whose prosthetic valve endocarditis was detected by multidetector computed tomography and who successfully underwent redo aortic valve replacement. Preoperative echocardiography revealed no remarkable findings related to endocarditis such as perivalvular leakage or vegetation; however, multidetector computed tomography revealed a thickened right coronary cusp. Intraoperatively, the right coronary cusp was confirmed to be covered with thick infected tissue. The pathological findings revealed broad destruction due to infection of the right coronary cusp. Conclusion: Multidetector computed tomography was useful in detecting infectious signs in prosthetic valves.

Are Mechanical Prostheses Valid Alternatives to the Ross Procedure in Young Children Under 6 Years Old?

Aortic valve replacement in young children is associated with technical difficulties and potential morbidity. In contrast to the versatile Ross operation, mechanical prostheses (MP) are uncommonly used. We examined transplant-free survival and cardiac reoperation among 124 young children (aged 1-6 years) who underwent the Ross operation (n= 84) or MP (n= 40) for congenital disease (1982-2003) using the Pediatric Cardiac Care Consortium database. We explored variables influencing outcomes. Children who received MP were operated in an earlier era and were more likely to have aortic regurgitation, conotruncal abnormalities, prior aortic valve surgery, and to need Konno annular enlargement. Although no significant differences were found in hospital mortality (1.2% vs 5.0%, P= .24) or 15-year transplant-free survival (94.1% vs 87.5%, P= .16) between Ross and MP recipients, survival diverged with later follow-up (91.3% vs 68.9%, respectively, at 25 years; P= .01). On multivariable regression analysis the association of MP use and transplant-free survival changed over time (hazard ratios, 0.8 [95% confidence interval, 0.1-4.4; P= .78] vs 6.0 [95% confidence interval, 0.6-63.1; P= .13], respectively) before and after 17 years. Cumulative incidence of cardiac reoperation at 10 years was 37.7% and 53.6% after the Ross procedure and MP, respectively (P= .05). The most common reoperation after the Ross procedure was conduit replacement and pacemaker ± automated internal cardiac defibrillator and after MP was pacemaker ± automated internal cardiac defibrillator and redo aortic valve replacement. Over the study period there was a trend for increased Ross utilization. Interestingly MP use was associated with comparable operative mortality and survival up to 17 years, albeit with higher need for redo aortic valve replacement. On longer follow-up survival diverged with increased attrition in the MP group, likely because of late valve- and reoperation-related complications.

A case of aggressive aortic prosthetic valve endocarditis aggressive caused by Staphylococcus lugdunensis

BackgroundStaphylococcus lugdunensis is a coagulase-negative Staphylococcus species, which are weak pathogenic bacteria generally. However, the acute and severe pathogenicity of Staphylococcus lugdunensis infective endocarditis may be due to the rapid growth of large vegetation and consequent valve destruction.Case presentationThe patient was an 81-year-old male who visited our hospital with chief complaints of low back pain and high fever. Four years before this visit, he had undergone aortic valve replacement for aortic regurgitation. He was found to be hypotensive. Although there is no heart murmur on auscultation and echocardiography revealed negative findings with aortic valve, a blood test showed increases in the white blood cell count and C-reactive protein concentration. On the next day, Gram-positive cocci were detected in a blood culture and echocardiography detected a large vegetation on the prosthetic valve with increased flow velocity. Therefore, he underwent redo aortic valve replacement emergently. Staphylococcus lugdunensis was identified in blood samples and vegetation culture. Consequently, the patient was treated with antibiotics for 5 weeks after the operation and discharged home.ConclusionsWe experienced rapidly progressive prosthetic valve endocarditis caused by Staphylococcus lugdunensis. Hence, Staphylococcus lugdunensis infective endocarditis requires aggressive treatment, and the pathogenicity of this coagulase-negative Staphylococcus with high drug susceptibility should not be underestimated.

TCT CONNECT-135 Comparison of Outcomes of Redo-Aortic Valve Replacement: Transcatheter Versus Surgical Approach

TCT CONNECT-135 Comparison of Outcomes of Redo-Aortic Valve Replacement: Transcatheter Versus Surgical Approach

Annulus root enlargement during redo aortic valve replacement: Perioperative results and hemodynamic impact

Redo aortic valve replacement (AVR) might present an increased risk for predicted patient-prosthesis mismatch (PPM). Aortic root enlargement (ARE) procedures can decrease PPM and improve hemodynamic parameters. It is crucial to evaluate the safety of ARE in the context of redo AVR to allow better patient selection. This is a matched case-control study of 125 patients who underwent a redo AVR between 1991 and 2016, 21 patients had a concomitant ARE procedure. Patients were matched for age, gender, presence of coronary artery disease, renal clearance, left ventricular ejection fraction, and body mass index. The primary outcome was the occurrence of major adverse cardiovascular events (MACE). Secondary outcomes were postoperative impact of the ARE procedures on echocardiographic measurements and survival. Preoperatively, indexed aortic valve area (0.49 vs 0.66 cm2 /m2 ; P = .02) and left ventricle outflow tract diameters (20.1 vs 22.2 mm; P < .01) were significantly smaller in the ARE group. ARE procedures increased the aortic valve area by an average of 0.4 cm2 (pre = 0.9, post = 1.3; P < .01), with a reduction of maximum and mean transvalvular gradients of 26.6 mm Hg (pre = 56.8, post = 30.2; P < .01) and 17.1 mm Hg (pre = 31.9, post = 14.8; P < .01), respectively. Postoperatively, the occurrence of MACE was similar (ARE = 19%, no ARE = 14%; P = .68). Survival rates were similar (P = .29). For patients undergoing redo AVR, ARE is not associated with higher perioperative mortality and morbidity when compared with patients undergoing AVR without ARE. The fear of perioperative complications potentially associated with ARE should not be a prohibiting factor in symptomatic redo patients with small aortic annulus and predicted PPM.

Diastolic blood pressure predicts outcomes after aortic paravalvular leak closure.

We sought to determine hemodynamic effects of aortic paravalvular leak (PVL) and predictors of clinical outcomes after aortic PVL closure. The significance of hemodynamic alterations in PVL and relation to severity, procedural success of percutaneous closure and clinical outcomes have not been defined. Patients undergoing percutaneous PVL closure between July 21, 2004 and September 10, 2018 were included. PVL severity was assessed by echocardiography and aortic angiography. Hemodynamics were assessed by intra-arterial pressure tracings before and after PVL closure. The primary outcome was a composite of mortality, redo aortic valve replacement (AVR) and redo PVL closure. One hundred and seventeen patients (mean age 70.3 ± 14.9 years, 79% surgical and 21% transcatheter prostheses) underwent PVL closure with 94% technical success. PVL was moderate or greater in 106 (91%) at baseline and 11 (11%) post-procedure. Diastolic BP for those with moderate or greater PVL was lower than for those with less PVL (50.3 ± 11.7 vs. 56.5 ± 12.4 mmHg, p < .001). Pulse pressure was similar between these groups (69.9 ± 20.3 vs. 67.4 ± 21.2 mmHg, p = .39). 35 patients (34%) had 40 events during a mean follow-up of 1.6 ± 1.9 years (23 deaths, 12 redo AVR, and five redo PVL closures). In a multivariate model, final diastolic BP <47 mmHg (HR 3.27 [1.45-7.36], p = .007) was a significant predictor of the composite endpoint. Diastolic BP was significantly associated with aortic PVL severity and clinical outcomes after PVL closure. In contrast, pulse pressure did not correlate with PVL severity or outcomes. These findings have implications for clinical management of patients with aortic PVL.

Surgical Complexity and Outcome of Patients Undergoing Re-do Aortic Valve Surgery

ObjectivesRe-do aortic valve surgery carries a higher mortality and morbidity compared with first time aortic valve replacement (AVR) and often requires concomitant complex procedures. Transcatheter aortic valve replacement (TAVR) is...

P709 Rare complication of delayed iatrogenic critical left main coronary (LMC) occlusion after a re-do aortic valve replacement (AVR) post an acute prosthetic valve intrinsic dysfunction in a young patient

Abstract Funding Acknowledgements Nil Introduction Delayed LMC obstruction is quite a rare but fatal complication of surgical AVR. It is iatrogenic however can be induced by embolization of aortic calcium plaque or surgical over-tightening of the new aortic valve suture ring over the LMC ostium during surgery Case report Herein, we report a case of LMC severe ostial obstruction that occurred 30 days post a re-do surgical AVR for a young 38-year-old male young patient. The patient presented with palpitations, dyspnea NYHA class III and general fatigue started 4 weeks earlier. Diagnosed by 2D transthoracic echo (TTE) as bicuspid aortic valve (BAV) with severe aortic regurgitation (AR), grade II-III mitral regurgitation (MR) and severe pulmonary hypertension with estimated LV ejection fraction (LVEF) of 40%. Transesophageal echo (TEE) confirmed the same however demonstrated the MR grade as severe. Hence posted for a double valve replacement (DVR) surgery. Preoperative coronary angiography (CAG) revealed normal coronaries. Intraoperative TEE showed well-functioning both prostheses. On day 5 postoperatively patient developed dyspnea, orthopnea and was restless. Bed side 2D echo both revealed severe eccentric AR with query one stuck disc of the AV prosthesis in the setting of acute severe LV dysfunction with LVEF of 20%. Cinefluoroscopy confirmed our diagnosis of one stuck disc in an opened position. We attempted to mobilize the disc using a 0.035 wire through the aorta, however, this proved unsuccessful. So, we scheduled the patient for an urgent redo AVR. Intraoperative inspection of the resected prosthesis ruled out thrombosis and revealed that the disc was immobile secondary to a manufacturing intrinsic defect. Intraoperative TEE confirmed a successful redo AVR with normal new prosthesis function. Patient made a steady recovery and was discharged 7 days later. Screening TTE before discharge showed improved LVEF from 20% to 35%. Patient presented 30 days later with new onset classic angina on effort. Our greatest fear of a complicated delayed iatrogenic critical LMC occlusion was proven on CAG that showed a discrete 90% stenosis of ostial LMC artery. we underwent an intravascular ultrasound (IVUS)- guided successful percutaneous coronary intervention to ostial LMC artery after which patient recovered very well. TTE before discharge showed further improvement of LVEF to 50%. He was followed up for two years later with no complications neither any symptoms. Conclusions Although a very rare complication, however endogenous intrinsic defect of the prosthetic valve might be fatal with acute decompensation and complications that merit immediate action. With the help of multimodal imaging we were able to timely diagnosis and illustrate the cause and extent of acute prosthesis dysfunction. It is very important to have a high diagnostic suspicion if signs of myocardial ischemia occur after surgical AVR even if delayed as occurred in our patient. Abstract P709 Figure. Severe AR-Prosthesis dysfunction-LM obst

Successful PCI for Left Main Stem Thrombus on an Open Chest and VA-ECMO

A 66-year-old woman underwent elective re-do aortic valve replacement, having previously undergone a Mitroflow bioprosthetic aortic valve replacement (Sorin Group USA, Arvada, Colorado), which had become severely stenosed. A 21-mm mechanical Carbomedics supra-annular Top Hat valve (Carbomedics,

Aortic valve repair techniques: an early UK experience

ObjectivesRetrospective review of early results with aortic valve repair (AVr) techniques.Methods61 consecutive patients underwent AVr surgery at our institutions between 2008 and 2018. 14 patients had a bicuspid aortic valve...

P3853Mortality of surgical redo aortic valve replacement versus transcatheter aortic valve-in-valve implantation in patients with degenerated aortic bioprosthesis: a meta-analysis

Abstract Background Transcatheter valve-in-valve (tVIV) implantation for degenerated aortic bioprosthesis has become an alternative to surgical aortic valve replacement (sAVR) in the past few years. However, some concerns have been raised regarding to the long-term safety and efficacy of tVIV. The objective was to compare the clinical and echocardiographic outcomes of tVIV implantation with redo cAVR. Methods After an extensive search of PubMed we included 7 observational studies (3 used propensity score matching) comparing tVIV versus sAVR in 762 patients The primary endpoint was all-cause mortality determined from the longest available survival data. Other outcomes of interest were stroke, permanent pacemaker implantation, paravalvular leak, hospital stay and postoperative aortic valve gradient. The review was conducted according to the MOOSE recomendations. Der Simonian and Laird random effects model was used to estimate summary measures and their 95% CI. Results Patients in the tVIV group were significantly older (78 vs 73 y.o.) and had a higher baseline risk compared to those in the re-sAVR group (Euroscore 19.7 vs 14.3). There was no statistical difference in procedural or 30-day mortality 5.4% vs 5.3% in tVIV and sAVR, respectively (RR 0.98, 95% CI 0.54–1.80; p=0.96], and long-term mortality (from 6 month to 5 years) 18.7% versus 16.5% (RR 1.13, 95% CI 0.80–1.60; P=0.50). The risk of stroke was similar (1.5% in tVIV vs 2.4% in sAVR, p=0.47). tVIV was associated with a significantly lower rate of permanent pacemaker implantations 6.9% vs 12.1% (RR 0.58, 95% CI 0.36–0.94; P=0.03) and shorter hospital length stay (7 days vs 12 days, p=0.02). However, echocardiographic postoperative aortic valve gradients were lower in sAVR group than in tVIV (RR 1.83, 95% CI 0.75–2.91, p&lt;0.001). 30-day and long-term mortality Conclusion This meta-analysis suggests that patients with aortic degenerated bioprosthesis treated with tVIV have similar 30-day and long-term mortality with lower need of permanent pacemaker and length stay than sAVR. Thus tVIV is a valid alternative to standard surgical treatment.

Severe Hypoxia and Compartment Syndrome in a Patient With Sickle Cell Trait After Redo Aortic Valve Replacement: A Case Report and Review of the Literature

Severe Hypoxia and Compartment Syndrome in a Patient With Sickle Cell Trait After Redo Aortic Valve Replacement: A Case Report and Review of the Literature

Structural valve deterioration does not alter tissue valves’ radiopaque landmarks: Implications for valve-in-valve therapy

BackgroundValve-in-valve is established as a safe and efficient alternative to redo surgery in the treatment of structural valve deterioration (SVD). In vitro models rely on the radiopaque landmarks of undeteriorated tissue valves to establish the optimal implantation level of the transcatheter heart valves inside the deteriorated valves. In computed assisted procedures, the radiopaque landmarks of the deteriorated valves may be used to guide valve implantation through image fusion. The purpose of this study is to determine whether SVD alters the radiopaque landmarks of stented tissue valves. MethodsOur approach was based on the computation of relevant anatomical measurements from CT images. Radiopaque landmarks of degenerated bioprostheses and the corresponding undeteriorated valves were extracted to create surface meshes and cloud points using grey-level thresholding. 3D registration using an iterative closest point algorithm was used to align the corresponding cloud points, while the modified Hausdorff Distance was applied to determine the differences between them. ResultsThe proposed evaluation was performed on 19 degenerated tissue valves. 15 valves were scanned from patients evaluated for valve-in-valve procedures, and 4 bioprostheses were scanned after surgical extraction during redo aortic valve replacement. All the degenerated valves were compared to the corresponding undeteriorated models. Overall, the mean difference between degenerated and undeteriorated valves was 0.33 ± 0.12 mm. The maximum observed registration error was 0.66 mm. ConclusionsOur study demonstrates no significant difference between the radiopaque landmarks of deteriorated and undeteriorated bioprostheses after the occurrence of SVD. Our findings suggest therefore that SVD does not alter radiopaque landmarks of stented tissue valves. These results validate in-vitro studies of optimal transcatheter heart valves implantation inside deteriorated tissue valves based on their radiopaque landmarks, and allow the use of non-deteriorated valves’ imaging features in computer assisted valve-in-valve procedures.

RF46 MINI-ACCESS ISOLATED AORTIC VALVE REOPERATION WITH PERCEVAL SUTURELESS PROSTHESIS

Background and aim: Literature data regarding the use of upper “J” hemi-sternotomy in reoperative aortic valve replacement show a reduction in the biological trauma primarily due to the limited mediastinal tissues dissection avoiding excessive blood loss. Based on encouraging results reported for minimally invasive aortic valve replacement and with sutureless prosthesis we decided to use the Perceval valve in redo aortic valve replacement with minimally invasive approach. Methods: Seven patients underwent redo aortic valve replacement using a sutureless Perceval bio-prosthesis with a minimally invasive approach: four (57%) patients received upper hemisternotomy and three (43%) a right minithoracotomy. The median age was 75.9 ± 5 years and 5 of them (71.4% of the cohort) was male.Mean preoperative euroSCORE was 10.7 ± 1.2. Previous operation included: coronary artery bypass grafts (n°3), isolated aortic valve replacement (n°2), combined procedure (n°2). Results: The operation was performed with total central cannulation in 6 (86%) patients, in the seventh the ascending aorta was cannulated but a femoral venous percutaneous cannula was preferred for extreme frailty of the right atrium. Mean cardiopulmonary bypass and aortic cross clamp times were 56.6 ± 29.8 (median 47) and 44.3 ± 26.9 (median 33) minutes. No conversion to full sternotomy was required. There was no hospital mortality within 30 days of operation. Conclusions: Mini-access isolated aortic valve surgery with sutureless prosthesis is a reproducible, safe and effective procedure also in case of reoperation. It can improve the outcome by minimizing trauma, preventing postoperative complications and it could be an alternative to valve in valve in selected patients.

RF81 SUTURELESS AORTIC PERCEVAL BIOPROSTHESIS IN CARDIAC REOPERATIONS: SINGLE CENTER EXPERIENCE

Background and Aim: Perceval sutureless aortic bioprosthesis (LivaNova, Italy) represents an innovative approach for surgical aortic valve replacement (AVR), in order to reduce operative time and facilitate prosthesis implantation, specially in complex procedures. We described our experience with Perceval bioprosthesis in cardiac reoperations (REDO). Methods: From March 2011 to December 2017, 841 patients underwent AVR with sutureless aortic Perceval bioprosthesis at our Institution. Of these, 72 patients had previously undergone cardiac surgery. Mean age was 73 ± 4 years, 33 patients were female (46%), and mean logistic EuroSCORE was 27.3 ± 14%. Preoperative, periprocedural and echocardiographic parameters, as well as clinical outcomes, were analyzed. Results: The primary procedure was aortic valve surgery in 46 patients (64%). Isolated REDO AVR was performed in 51 patients (71%). REDO surgery was performed via full sternotomy in 63 patients (87.5%) and via right minithoracotomy in 9 patients (12.5%). Cardiopulmonary bypass and aortic cross-clamp times were 98.4 ± 34.3 and 53.3 ± 35.7 minutes for isolated AVR and 176.4 ± 71.5 and 108.1 ± 39.7 minutes for combined procedures. In-hospital deaths occurred in 4 patients (5.5%), two patient had cardiac death, and all patients were alive at a mean follow-up of 28.6 ± 12.4 months. Pacemaker implantation was performed in 4 patients. On echocardiographic evaluation, no patient showed paraprosthetic leakages and mean transprosthesis gradient was 10.4 ± 6.3 mmHg. Conclusions: Perceval sutureless AVR is a fast and safe procedure, even in high-risk REDO surgery, providing a good hemodynamic performance with excellent clinical results.

TCT-338 Comparison of Re-Do transcatheter aortic valve replacement with valve-in-valve for failed surgical aortic bioprostheses: a multicenter analysis of clinical and long-term outcome

Valve-in-Valve (ViV) for failed surgical aortic valve replacement (SAVR) is an effective treatment for patients that are not able to undergo re-operation. Limited data exist for transcatheter aortic valve replacement (TAVR) as a redo for patients that have undergone TAVR procedures. Baseline

The Ross procedure in adults presenting with bicuspid aortic valve and pure aortic regurgitation: 85% freedom from reoperation at 20 years.

The Ross procedure has demonstrated excellent results when performed in patients with aortic stenosis or mixed aortic valve disease [aortic stenosis and aortic regurgitation (AR)]. However, due to its reported risk of late reoperation, it is not recommended under current guidelines for patients presenting with bicuspid aortic valve and pure AR. We have analysed our own results in light of this recommendation. Between 1993 and 2016, 129 consecutive patients with a mean age of 34.7 ± 10.6 years (range 16-64 years) presented with bicuspid aortic valve and pure AR and underwent the Ross procedure. Patients were reviewed annually and had 2nd yearly transthoracic echocardiograms during follow-up. The unit had a liberal reoperation policy where reoperation was performed if patients developed recurrent moderate or greater AR during follow-up. There was 1 inpatient death, and 3 late deaths over a mean follow-up duration of 9.6 ± 6.8 years. Late survival at 10 and 20 years post-surgery were 99% [95% confidence interval (CI) 94-100] and 95% (95% CI 85-99), respectively. Eleven patients underwent redo aortic valve replacement (AVR) and 4 patients had redo pulmonary valve replacement. Freedom from reoperation for AVR and more-than-mild AR at 10 and 20 years post-surgery were 89% (95% CI 81-94) and 85% (95% CI 74-92), respectively. Having longer aortic cross-clamp (hazard ratio 1.03, 95% CI 1.00-1.06; P = 0.05) and cardiopulmonary bypass times (hazard ratio 1.02, 95% CI 1.00-1.05; P = 0.05), and having a larger preoperative sinotubular junction diameter (hazard ratio 1.15, 95% CI 1.03-1.30; P = 0.02) were significant predictors of having redo AVR or significant AR at follow-up. With a 20-year freedom from redo AVR and greater-than-mild residual AR of 85%, the utilization of the Ross procedure in bicuspid aortic valve patients with pure AR should be considered.

AORTIC ROOT ENLARGEMENT IN REDO AORTIC VALVE REPLACEMENT WITH PREDICTED PATIENT-PROSTHESIS MISMATCH

Patients with previous aortic valve replacement (AVR) who undergo reoperation are at higher risk of patient-prosthesis mismatch (PPM), due to annulus fibrosis and restriction after prosthesis extraction. Aortic root enlargement (ARE) can prevent PPM but its safety during redo-AVR is unknown. Cross-