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Calcified aortic homograft and sutureless valves
CRVASA-259; No. of Pages 4 cor et vasa xxx (2015) e1–e4
Available online at www.sciencedirect.com
ScienceDirect journal homepage: http://www.elsevier.com/locate/crvasa
Case report
Calcified aortic homograft and sutureless valves Júlia Čanádyová a,*, Aleš Mokráček a,b,c,1 a
Kardiochirurgické oddělení Nemocnice České Budějovice, a.s., B. Němcové 54, 37001 České Budějovice, Czech Republic b IKEM, Praha, Czech Republic c Zdravotně sociální fakulta, Jihočeská Univerzita České Budějovice, Czech Republic
article info
abstract
Article history:
The use of sutureless valves in the case of a heavily calcified aortic homograft allows for
Received 15 January 2015
relatively quick and safe replacement. Due to the nitinol frame, which is self-anchored in the
Received in revised form
aortic valve annulus and in the sinotubular junction (STJ), no complete annular decalcifica-
27 January 2015
tion or fixation with stitches is required. In conditions of significant calcification this may
Accepted 2 February 2015
represent a technical problem.
Available online xxx
# 2015 The Czech Society of Cardiology. Published by Elsevier Urban & Partner Sp. z o.o. All rights reserved.
Keywords: Aortic stenosis Calcified homograft Sutureless bioprosthesis
Introduction Aortic valve stenosis is the most common valve disease in Europe and North America. Calcified aortic stenosis occurs in 2–7% of the population older than 65 years. According to various literature data up to 30–60% of symptomatic patients with significant aortic stenosis are not indicated for surgical intervention, most often due to old age or associated comorbidities [1–3]. In this case, the prognosis of untreated patients with symptomatic severe aortic stenosis is poor; the 5-year survival rate is between 15 and 50% [1,3]. The only effective and efficient treatment of symptomatic aortic
valve stenosis is valve replacement (class I recommendation, ESC/EACTS guidelines on the management of valvular heart disease (2012)) [4]. The conventional treatment of severe aortic stenosis is surgical replacement of the valve through a median sternotomy using cardiopulmonary bypass (CPB). In order to minimize periprocedural risks and to accelerate postoperative rehabilitation, less invasive approaches have been developed and are increasingly used while maintaining quality and safety. At the same time the occurrence of older and sicker patients is also increasing [5,6]. The current patients are often with a heavily calcified valve, aortic root or diffuse atherosclerosis of the aortic wall after a previous aortic valve replacement. This has led to the development of less invasive therapeutic
* Corresponding author. Tel.: +420 387874201. E-mail addresses: [email protected] (J. Čanádyová), [email protected] (A. Mokráček). 1 Tel.: +420 387874201. http://dx.doi.org/10.1016/j.crvasa.2015.02.001 0010-8650/# 2015 The Czech Society of Cardiology. Published by Elsevier Urban & Partner Sp. z o.o. All rights reserved.
Please cite this article in press as: J. Čanádyová, A. Mokráček, Calcified aortic homograft and sutureless valves, Cor et Vasa (2015), http://dx. doi.org/10.1016/j.crvasa.2015.02.001
CRVASA-259; No. of Pages 4
e2
cor et vasa xxx (2015) e1–e4
concepts, including transcatheter aortic valve implantation (TAVI) and sutureless bioprosthesis.
Case report We describe the case of a 70-year-old female patient with hypertension, dyslipidemia, hypothyroidism on replacement therapy for thyroid lobectomy in 2012 and severe stenosis of the aortic homograft. In 2005 the patient underwent persistent foramen ovale (PFO) closure and aortic valve replacement with an aortic homograft due to infective endocarditis. The patient was admitted to our department in March 2014 for worsening dyspnea, NYHA II– III. She was without chest pain and syncope. An echocardiographic examination confirmed severe stenosis of the aortic homograft, with peak gradient (PG) 100 and mean gradient (MG) 58 mmHg and indexed aortic valve area (AVAi) 0.35 cm2/m2. Coronary angiogram examination excluded significant coronary artery disease. The logistic EuroSCORE was 10.77%. The patient was indicated for valve replacement. Because of the higher operative risk, during the decision-making process the patient was considered for transcatheter aortic valve implantation (TAVI) or implantation of a sutureless bioprosthesis. Based on preoperative CT scans of the aorta, which revealed a significant calcification of the valve, aortic root and ascending aorta, we decided to use the sutureless valve (Fig. 2). A major reason was the high calcium score and in our opinion it was also due to the higher risk of paravalvular insufficiency in TAVI.
Surgical procedure The procedure was performed in a standard operating room; general anesthesia and systemic heparinization were performed. The heart was exposed through a median sternotomy because of reoperation. The ascending aorta and right atrium appendage were cannulated and the patient was placed on cardiopulmonary bypass (CPB). After aortic cross-clamping the antegrade infusion of cold blood cardioplegia was delivered. The aortic bioprosthesis Perceval S is made from a bovine pericardial valve mounted on a compressible and expandable metal frame in nitinol, with unique features and mechanical behavior (Fig. 1A). The valve prosthesis is loaded and collapsed into a delivery device (Fig. 1B). Collapsing increases the visibility and preserves the integrity of the valve leaflets. The reduced collapsed profile prevents trauma to the aortic wall, enabling a full and direct view. To ensure correct positioning of the prosthesis, three guiding threads are temporarily positioned in the lowest part of the native leaflet insertion line for each valve sinus and the corresponding part of the bioprosthesis as reference points for accurate alignment of the inflow section of the prosthesis with the insertion plane of the native leaflets (Fig. 1C). The temporary guiding threads suture the valve by guiding it along the annulus axis even in narrow spaces. Once the prosthesis is deployed and released, the guiding threads are removed (Fig. 1D) [5]. A transverse aortotomy was done 1 cm distal to the sinotubular junction so as to leave an edge free for closure of the aortotomy after implantation of the device and to prevent
Fig. 1 – (A) Perceval S valve. (B) The holder device and valve collapsing. (C) Three guide threads. (D) Completely deployed prosthesis into the annulus. Please cite this article in press as: J. Čanádyová, A. Mokráček, Calcified aortic homograft and sutureless valves, Cor et Vasa (2015), http://dx. doi.org/10.1016/j.crvasa.2015.02.001
CRVASA-259; No. of Pages 4 cor et vasa xxx (2015) e1–e4
e3
Fig. 2 – Preoperative CT angiogram showed calcified aortic homograft, root and the ascending aorta.
Please cite this article in press as: J. Čanádyová, A. Mokráček, Calcified aortic homograft and sutureless valves, Cor et Vasa (2015), http://dx. doi.org/10.1016/j.crvasa.2015.02.001
CRVASA-259; No. of Pages 4
e4
cor et vasa xxx (2015) e1–e4
interference of the metal frame with closure of the aortotomy. The calcified aortic homograft was removed and the aortic annulus was decalcified. After measuring the size of the valve – as the free passage of the transparent portion of the sizer through the annulus into the left ventricle but not free passage of the white portion into the ventricle – the prosthesis ‘‘M’’ was chosen. During the valve collapse, the three guiding threads were positioned. The release device is inserted into the aorta down to the point where it was blocked by pulling the previously positioned guiding threads. The valve prosthesis, loaded into the delivery device, was released in two phases, the inflow section opens first, while full release of the prosthesis is obtained only after opening of the outflow part. Once the prosthesis was completely deployed, the guiding threads were removed. To optimize the area of contact between the prosthesis and the aortic annulus, a post-dilatation is carried out with a balloon catheter at a pressure of four atmospheres. After weaning from CPB, the sternum and wound were closed in the standard manner. The duration of the ischemic arrest was 34 min and CPB time was 61 min. The control intraoperative transesophageal echocardiography was favorable, with no paravalvular leak or other dysfunctions of the prosthesis with a gradient PG/MG 20/14 mmHg. The patient was transported to the intensive care unit and further course was uneventful. The patient was discharged on the eighth postoperative day.
Discussion In order to minimize mortality and to extend the indications of surgical treatment for high-risk, otherwise inoperable patients, less invasive alternative approaches using innovative technologies have been developed [6]. Transcatheter aortic valve implantation (TAVI) and sutureless valve represent two of the most important advances in the treatment of aortic valve diseases in recent years [6]. Similar to conventional surgical replacement of the valve, sutureless bioprosthesis requires valve excision (risk reduction of paravalvular insufficiency compared with TAVI) and annular decalcification, but permanent fixation sutures are not required [6]. The possibility of avoiding sutures placement and their tidying may lead to shorter procedural times. In cardiac surgery, prolonged CPB and cross-clamp time duration are strong independent risk factors for postoperative mortality and morbidity [7,8]. These advantages could be of benefit to patients who have no fundamental contraindications for using cardiopulmonary bypass and are undergoing complex, combined procedures or re-operations. Patients with a small aortic annulus or heavy calcification of the annulus and aortic root, where sutures positioning may represent technical problems and complications, are another potential group that could benefit.
Conclusion Sutureless aortic bioprosthesis represents a new generation of bioprosthesis and another therapeutic option in the spectrum of aortic valve replacement.
They combine the advantages of stentless valves in terms of hemodynamic parameters (a more efficient effective orifice area – EOA) and simple and safe implantation. The potential to reduce operative time may be beneficial in sicker elderly patients undergoing combined surgeries and reoperation, and their construction enables and supports minimally invasive approaches in cardiac surgery (insertion through the partial sternotomy or right thoracotomy).
Conflict of interest There are no known conflicts of interest associated with this publication.
Funding body There is no financial support for the preparation of the article.
Ethical statement The case report was written according to ethical standards.
Informed consent The patient provided the informed verbal consent to participate in the case report.
references
[1] E. Charlson, A.T.R. Legedza, M.B. Hamel, Decision-making and outcomes in severe symptomatic aortic stenosis, The Journal of Heart Valve Disease 15 (2006) 312–321. [2] P.A. Pellikka, M.E. Sarano, R.A. Nishimura, et al., Outcome of 622 adults with asymptomatic, hemodynamically significant aortic stenosis during prolonged follow-up, Circulation 111 (2005) 3290–3295. [3] B. Iung, G. Baron, E.G. Butchart, et al., A prospective survey of patients with valvular heart disease in Europe: the Euro Heart Survey on Valvular Heart Disease, European Heart Journal 24 (2003) 1231–1243. [4] J. Popelová, M. Brtko, P. Němec, Summary of the ESC guidelines on the management of valvular heart disease (version 2012). Prepared by the Czech Society of Cardiology, Cor et Vasa 55 (2013) e41–e56. [5] A. Mokráček, J. Čanádyová, V. Kurfirst, et al., Sutureless aortic bioprotheses – initial experience with Sorin Perceval S prosthesis, Intervenční a Akutní Kardiologie 12 (3) (2013) 121–123. [6] K. Phan, Y.C. Tsai, N. Niranjan, et al., Sutureless aortic valve replacement: a systematic review and meta-analysis, Annals of Cardiothoracic Surgery 27 (April) (2014) 1–13. [7] T.A. Folliguet, F. Laborde, K. Zannis, et al., Sutureless Perceval aortic valve replacement: results of two European Centers, The Annals of Thoracic Surgery 93 (2012) 1483–1488. [8] A.N. Saraf, L. Thalib, A. Hughes, et al., Cross-clamp time is an independent predictor of mortality and morbidity in low and high-risk cardiac patients, International Journal of Surgery 9 (2011) 104–109.
Please cite this article in press as: J. Čanádyová, A. Mokráček, Calcified aortic homograft and sutureless valves, Cor et Vasa (2015), http://dx. doi.org/10.1016/j.crvasa.2015.02.001
Available online at www.sciencedirect.com
ScienceDirect journal homepage: http://www.elsevier.com/locate/crvasa
Case report
Calcified aortic homograft and sutureless valves Júlia Čanádyová a,*, Aleš Mokráček a,b,c,1 a
Kardiochirurgické oddělení Nemocnice České Budějovice, a.s., B. Němcové 54, 37001 České Budějovice, Czech Republic b IKEM, Praha, Czech Republic c Zdravotně sociální fakulta, Jihočeská Univerzita České Budějovice, Czech Republic
article info
abstract
Article history:
The use of sutureless valves in the case of a heavily calcified aortic homograft allows for
Received 15 January 2015
relatively quick and safe replacement. Due to the nitinol frame, which is self-anchored in the
Received in revised form
aortic valve annulus and in the sinotubular junction (STJ), no complete annular decalcifica-
27 January 2015
tion or fixation with stitches is required. In conditions of significant calcification this may
Accepted 2 February 2015
represent a technical problem.
Available online xxx
# 2015 The Czech Society of Cardiology. Published by Elsevier Urban & Partner Sp. z o.o. All rights reserved.
Keywords: Aortic stenosis Calcified homograft Sutureless bioprosthesis
Introduction Aortic valve stenosis is the most common valve disease in Europe and North America. Calcified aortic stenosis occurs in 2–7% of the population older than 65 years. According to various literature data up to 30–60% of symptomatic patients with significant aortic stenosis are not indicated for surgical intervention, most often due to old age or associated comorbidities [1–3]. In this case, the prognosis of untreated patients with symptomatic severe aortic stenosis is poor; the 5-year survival rate is between 15 and 50% [1,3]. The only effective and efficient treatment of symptomatic aortic
valve stenosis is valve replacement (class I recommendation, ESC/EACTS guidelines on the management of valvular heart disease (2012)) [4]. The conventional treatment of severe aortic stenosis is surgical replacement of the valve through a median sternotomy using cardiopulmonary bypass (CPB). In order to minimize periprocedural risks and to accelerate postoperative rehabilitation, less invasive approaches have been developed and are increasingly used while maintaining quality and safety. At the same time the occurrence of older and sicker patients is also increasing [5,6]. The current patients are often with a heavily calcified valve, aortic root or diffuse atherosclerosis of the aortic wall after a previous aortic valve replacement. This has led to the development of less invasive therapeutic
* Corresponding author. Tel.: +420 387874201. E-mail addresses: [email protected] (J. Čanádyová), [email protected] (A. Mokráček). 1 Tel.: +420 387874201. http://dx.doi.org/10.1016/j.crvasa.2015.02.001 0010-8650/# 2015 The Czech Society of Cardiology. Published by Elsevier Urban & Partner Sp. z o.o. All rights reserved.
Please cite this article in press as: J. Čanádyová, A. Mokráček, Calcified aortic homograft and sutureless valves, Cor et Vasa (2015), http://dx. doi.org/10.1016/j.crvasa.2015.02.001
CRVASA-259; No. of Pages 4
e2
cor et vasa xxx (2015) e1–e4
concepts, including transcatheter aortic valve implantation (TAVI) and sutureless bioprosthesis.
Case report We describe the case of a 70-year-old female patient with hypertension, dyslipidemia, hypothyroidism on replacement therapy for thyroid lobectomy in 2012 and severe stenosis of the aortic homograft. In 2005 the patient underwent persistent foramen ovale (PFO) closure and aortic valve replacement with an aortic homograft due to infective endocarditis. The patient was admitted to our department in March 2014 for worsening dyspnea, NYHA II– III. She was without chest pain and syncope. An echocardiographic examination confirmed severe stenosis of the aortic homograft, with peak gradient (PG) 100 and mean gradient (MG) 58 mmHg and indexed aortic valve area (AVAi) 0.35 cm2/m2. Coronary angiogram examination excluded significant coronary artery disease. The logistic EuroSCORE was 10.77%. The patient was indicated for valve replacement. Because of the higher operative risk, during the decision-making process the patient was considered for transcatheter aortic valve implantation (TAVI) or implantation of a sutureless bioprosthesis. Based on preoperative CT scans of the aorta, which revealed a significant calcification of the valve, aortic root and ascending aorta, we decided to use the sutureless valve (Fig. 2). A major reason was the high calcium score and in our opinion it was also due to the higher risk of paravalvular insufficiency in TAVI.
Surgical procedure The procedure was performed in a standard operating room; general anesthesia and systemic heparinization were performed. The heart was exposed through a median sternotomy because of reoperation. The ascending aorta and right atrium appendage were cannulated and the patient was placed on cardiopulmonary bypass (CPB). After aortic cross-clamping the antegrade infusion of cold blood cardioplegia was delivered. The aortic bioprosthesis Perceval S is made from a bovine pericardial valve mounted on a compressible and expandable metal frame in nitinol, with unique features and mechanical behavior (Fig. 1A). The valve prosthesis is loaded and collapsed into a delivery device (Fig. 1B). Collapsing increases the visibility and preserves the integrity of the valve leaflets. The reduced collapsed profile prevents trauma to the aortic wall, enabling a full and direct view. To ensure correct positioning of the prosthesis, three guiding threads are temporarily positioned in the lowest part of the native leaflet insertion line for each valve sinus and the corresponding part of the bioprosthesis as reference points for accurate alignment of the inflow section of the prosthesis with the insertion plane of the native leaflets (Fig. 1C). The temporary guiding threads suture the valve by guiding it along the annulus axis even in narrow spaces. Once the prosthesis is deployed and released, the guiding threads are removed (Fig. 1D) [5]. A transverse aortotomy was done 1 cm distal to the sinotubular junction so as to leave an edge free for closure of the aortotomy after implantation of the device and to prevent
Fig. 1 – (A) Perceval S valve. (B) The holder device and valve collapsing. (C) Three guide threads. (D) Completely deployed prosthesis into the annulus. Please cite this article in press as: J. Čanádyová, A. Mokráček, Calcified aortic homograft and sutureless valves, Cor et Vasa (2015), http://dx. doi.org/10.1016/j.crvasa.2015.02.001
CRVASA-259; No. of Pages 4 cor et vasa xxx (2015) e1–e4
e3
Fig. 2 – Preoperative CT angiogram showed calcified aortic homograft, root and the ascending aorta.
Please cite this article in press as: J. Čanádyová, A. Mokráček, Calcified aortic homograft and sutureless valves, Cor et Vasa (2015), http://dx. doi.org/10.1016/j.crvasa.2015.02.001
CRVASA-259; No. of Pages 4
e4
cor et vasa xxx (2015) e1–e4
interference of the metal frame with closure of the aortotomy. The calcified aortic homograft was removed and the aortic annulus was decalcified. After measuring the size of the valve – as the free passage of the transparent portion of the sizer through the annulus into the left ventricle but not free passage of the white portion into the ventricle – the prosthesis ‘‘M’’ was chosen. During the valve collapse, the three guiding threads were positioned. The release device is inserted into the aorta down to the point where it was blocked by pulling the previously positioned guiding threads. The valve prosthesis, loaded into the delivery device, was released in two phases, the inflow section opens first, while full release of the prosthesis is obtained only after opening of the outflow part. Once the prosthesis was completely deployed, the guiding threads were removed. To optimize the area of contact between the prosthesis and the aortic annulus, a post-dilatation is carried out with a balloon catheter at a pressure of four atmospheres. After weaning from CPB, the sternum and wound were closed in the standard manner. The duration of the ischemic arrest was 34 min and CPB time was 61 min. The control intraoperative transesophageal echocardiography was favorable, with no paravalvular leak or other dysfunctions of the prosthesis with a gradient PG/MG 20/14 mmHg. The patient was transported to the intensive care unit and further course was uneventful. The patient was discharged on the eighth postoperative day.
Discussion In order to minimize mortality and to extend the indications of surgical treatment for high-risk, otherwise inoperable patients, less invasive alternative approaches using innovative technologies have been developed [6]. Transcatheter aortic valve implantation (TAVI) and sutureless valve represent two of the most important advances in the treatment of aortic valve diseases in recent years [6]. Similar to conventional surgical replacement of the valve, sutureless bioprosthesis requires valve excision (risk reduction of paravalvular insufficiency compared with TAVI) and annular decalcification, but permanent fixation sutures are not required [6]. The possibility of avoiding sutures placement and their tidying may lead to shorter procedural times. In cardiac surgery, prolonged CPB and cross-clamp time duration are strong independent risk factors for postoperative mortality and morbidity [7,8]. These advantages could be of benefit to patients who have no fundamental contraindications for using cardiopulmonary bypass and are undergoing complex, combined procedures or re-operations. Patients with a small aortic annulus or heavy calcification of the annulus and aortic root, where sutures positioning may represent technical problems and complications, are another potential group that could benefit.
Conclusion Sutureless aortic bioprosthesis represents a new generation of bioprosthesis and another therapeutic option in the spectrum of aortic valve replacement.
They combine the advantages of stentless valves in terms of hemodynamic parameters (a more efficient effective orifice area – EOA) and simple and safe implantation. The potential to reduce operative time may be beneficial in sicker elderly patients undergoing combined surgeries and reoperation, and their construction enables and supports minimally invasive approaches in cardiac surgery (insertion through the partial sternotomy or right thoracotomy).
Conflict of interest There are no known conflicts of interest associated with this publication.
Funding body There is no financial support for the preparation of the article.
Ethical statement The case report was written according to ethical standards.
Informed consent The patient provided the informed verbal consent to participate in the case report.
references
[1] E. Charlson, A.T.R. Legedza, M.B. Hamel, Decision-making and outcomes in severe symptomatic aortic stenosis, The Journal of Heart Valve Disease 15 (2006) 312–321. [2] P.A. Pellikka, M.E. Sarano, R.A. Nishimura, et al., Outcome of 622 adults with asymptomatic, hemodynamically significant aortic stenosis during prolonged follow-up, Circulation 111 (2005) 3290–3295. [3] B. Iung, G. Baron, E.G. Butchart, et al., A prospective survey of patients with valvular heart disease in Europe: the Euro Heart Survey on Valvular Heart Disease, European Heart Journal 24 (2003) 1231–1243. [4] J. Popelová, M. Brtko, P. Němec, Summary of the ESC guidelines on the management of valvular heart disease (version 2012). Prepared by the Czech Society of Cardiology, Cor et Vasa 55 (2013) e41–e56. [5] A. Mokráček, J. Čanádyová, V. Kurfirst, et al., Sutureless aortic bioprotheses – initial experience with Sorin Perceval S prosthesis, Intervenční a Akutní Kardiologie 12 (3) (2013) 121–123. [6] K. Phan, Y.C. Tsai, N. Niranjan, et al., Sutureless aortic valve replacement: a systematic review and meta-analysis, Annals of Cardiothoracic Surgery 27 (April) (2014) 1–13. [7] T.A. Folliguet, F. Laborde, K. Zannis, et al., Sutureless Perceval aortic valve replacement: results of two European Centers, The Annals of Thoracic Surgery 93 (2012) 1483–1488. [8] A.N. Saraf, L. Thalib, A. Hughes, et al., Cross-clamp time is an independent predictor of mortality and morbidity in low and high-risk cardiac patients, International Journal of Surgery 9 (2011) 104–109.
Please cite this article in press as: J. Čanádyová, A. Mokráček, Calcified aortic homograft and sutureless valves, Cor et Vasa (2015), http://dx. doi.org/10.1016/j.crvasa.2015.02.001