- Email: [email protected]
Intraoperative Failure of Pericardial Mitral Valve Requiring Emergent Reoperation Minutes After Replacement
Intraoperative Failure of Pericardial Mitral Valve Requiring Emergent Reoperation Minutes After Replacement Mamta Thukral, MD,* and Marc Kanchuger, MD†
F
AILURE OF bioprosthetic valves implanted in the mitral position may occur months or years after the procedure because of a myriad of reasons. The authors present a case of intraoperative failure of a newly placed Carpentier-Edwards (Irvine, CA) bioprosthesis that was rapidly diagnosed by a transesophageal echocardiographic (TEE) examination. CASE REPORT An 81-year-old woman with coronary artery disease, hypertension, type 2 diabetes mellitus, and congestive heart failure (New York Heart Association class III) was admitted to the hospital with a history of lightheadedness and dyspnea. Cardiac catheterization showed severe triple-vessel coronary artery disease with complete occlusion of the left anterior descending, circumflex, and right coronary arteries. A TEE examination revealed severe mitral annulus calcification, severe mitral regurgitation, mild aortic stenosis, mild aortic insufficiency, and a normal ejection fraction. She was scheduled for an elective coronary artery bypass graft surgery operation with a mitral valve replacement under general anesthesia with standard and invasive monitoring including an arterial catheter, pulmonary artery catheter, and transesophageal echocardiogram. The operative approach included a sternotomy, bicaval cannulation, and retrograde cardioplegia. The patient first underwent coronary artery bypass graft surgery of her left anterior descending, first marginal, and second marginal arteries with no complications. The mitral valve was exposed through a left atriotomy revealing degenerated valve leaflets and severe annulus calcification. After the annulus was debrided, the anterior leaflet was excised, and the mitral orifice was sized for a no. 27-mm stented Carpentier-Edwards pericardial prosthesis (model #6900). Pledgeted annular sutures were placed through the sewing ring, but the valve did not seat properly because of extensive annular calcification. On testing the valve with an intraventricular saline injection, it was noted to be centrally incompetent without evidence of leaflet trapping. The prosthetic valve was removed, the annulus was debrided, and a second larger stented pericardial prosthesis (29-mm; Edwards Lifesciences, Irvine, CA) was seated and sutured with no difficulty. After atrial closure, air was evacuated from the heart and the patient
Fig 2. Intraoperative TEE revealing severe mitral regurgitation after valve replacement with Carpentier-Edwards pericardial bioprosthesis.
rewarmed to discontinue cardiopulmonary bypass (CPB). At this time, TEE examination of the heart revealed severe mitral insufficiency with total failure of the prosthetic valve leaflets to coapt with each other (Figs 1 and 2). The patient was recooled to 30°C and cardioplegic arrest repeated. Examination of the valve revealed severe tethering of leaflets as a result of a structural defect (Figs 3 and 4). The subvalvular area did not show any retraction of valve leaflets with suture. Retesting of the valve after pledgets and sutures were removed still showed significant tethering and insufficiency. The valve was replaced by a stented porcine xenograft (29-mm Mosaic; Medtronic, Minneapolis, MN). The patient was weaned from CPB again after a total of 314 minutes and cross-clamp times of 136 ⫹ 95 minutes. A postbypass transesophageal echocardiogram revealed good valve function along with hypokinetic inferior and posterior myocardium. The patient had a complicated postoperative course including hemiparesis and a sternal wound infection and expired after 6 months. DISCUSSION
The most common cause of intraoperative prosthetic valve failure is severe paravalvular leak. Mechanical or prosthetic valve failure occurring days or months after implantation has been reported in the literature,1,2 but immediate failure because of a valve defect is rare. Late failures are attributed to technical problems (residual para-annular tissue, entrapment of mitral
Fig 1. Intraoperative TEE showing failure of newly implanted mitral prosthesis valve leaflets to coapt.
From the *Department of Anesthesia, Children’s Hospital Boston, Boston, MA; and †Department of Anesthesia, Division of Cardiothoracic Anesthesia, New York University School of Medicine, New York, NY. Address reprint requests to Mamta Thukral, MD, Children’s Hospital Boston, 300 Longwood Avenue, Boston, MA 02115. E-mail: [email protected] © 2007 Elsevier Inc. All rights reserved. 1053-0770/07/2101-0019$32.00/0 doi:10.1053/j.jvca.2005.09.003 Key words: prosthetic mitral valve, transesophageal echocardiogram, intraoperative valve failure, cardiac surgery
Journal of Cardiothoracic and Vascular Anesthesia, Vol 21, No 1 (February), 2007: pp 93-95
93
94
THUKRAL AND KANCHUGER
Fig 3. Structural defects seen in explanted mitral pericardial bioprosthesis that resulted in severe regurgitation intraoperatively. (Color version of figure is available online.)
Fig 5. Normally functioning Carpentier-Edwards mitral bioprosthesis will usually show mild central regurgitation and one or more jets along the stent posts. (Color version of figure is available online.)
chordal apparatus, thrombus, suture loops, or excessively long suture tails) or unusual postoperative complications.3,4 Studies on Carpentier-Edwards pericardial prosthetic valves have revealed excellent long-term results with few early postoperative failures, but no reported intraoperative problems.5,6 To the authors’ knowledge, this is the only reported case of acute valve failure occurring because of tethering of valve leaflets that was detected before the patient was taken off CPB. Studies have indicated that routine intraoperative TEE examination is not only clinically beneficial in patients undergoing valvular surgery, but is also cost-effective in tertiary care centers.7 A transesophageal echocardiogram provides a powerful means to define the mechanisms of mitral regurgitation and identify the suitability of patients for valvuloplasty.8-10 A routine TEE examination after valve replacement allows visualization and assessment for structural abnormalities, transvalvular flow, paravalvular leaks, and regurgitation.11 The echocardiographer must be aware of signature flow patterns of
normally functioning prosthetic valves. Because of its basic design, the Carpentier-Edwards pericardial valve shows traceto-mild central regurgitation and one or more jets along the coaptation edge of the leaflets12 (Fig 5). This finding may not be seen on a postoperative transthoracic echocardiogram, but is usually benign and expected to continue for the duration of the valve. Leakage through the cloth portion of the valve (Fig 6) may also be seen but, unlike signature flow patterns, is usually temporary and disappears intraoperatively after giving protamine. Significant abnormal findings include moderate-to-severe central regurgitation, large paravalvular leaks, eccentric jets, suboptimal coaptation of valve leaflets, and interference of valve function by subvalvular apparatus. In addition, a risk for all stented valves is strut entrapment by suture loops or subvalvular apparatus, restricting leaflet movement and resulting in moderate-to-severe regurgitation. TEE interpretations are operator-dependent and subject to variability because of instru-
Fig 4. The valve leaflets of the explanted pericardial mitral valve show severe tethering. (Color version of figure is available online.)
Fig 6. Leakage through cloth portion of the valve may temporarily result in one or more trivial jets of mitral regurgitation. (Color version of figure is available online.)
PERICARDIAL MITRAL VALVE
95
ment settings (probe position, orientation, and gain) and patient factors (volume status, blood pressure, and presence of echo window), necessitating a careful and thorough examination to detect potentially disastrous situations. The intraoperative transesophageal echocardiogram is a powerful tool and provides high-resolution analysis of most intracardiac pathologies. Early failure of pericardial prosthetic valves can have several mechanisms. In a case series, 35 of 68 patients undergoing mitral valve replacements with the Ionescu-Shiley (Pfizer Inc, New York, NY) bovine pericardial prosthesis required reoperation because of primary tissue failure of bioprosthesis.13 Cusp tears, which were considered the dominant cause of sudden and progressive valve failure, were observed in all of the valves. This pointed to faulty valve mechanics and engineering. Another study reported failure of the Sorin-Pericarbon (Sorin Biomedica Cardio S.p.A., Via Crescentino, Italy) pericardial valve (aortic and mitral) prostheses in 10 of 144 patients, primarily because of early valvular stenosis (7/10 valves) that was caused by severe calcification of commissural as well
as basal regions of the valve leaflets.14 Cusp tearing was observed in only 2 cases. A consecutive series studying the Mitroflow (Sorin Group Canada, Inc, Burnaby, BC, Canada) pericardial bioprostheses, inserted in the mitral and aortic positions, revealed valve failures primarily because of collagen degeneration that was seen in all explanted valves.15 The areas of tissue degeneration were the major sites of calcification in the valves, which led to questions about the adequacy of the methods used in valve harvesting, processing, and glutaraldehyde preservation. In the present case, intraoperative valve failure was postulated to be caused by suture entrapment around the valve struts as a result of valve design. Entrapment can occur in Carpentier-Edwards bovine mitral pericardial prosthesis because of low-profile valve struts, and can be difficult to diagnose after the valve is seated in place. Hopefully, modifications are being made in the valve design to overcome this problem.
REFERENCES 1. Thomson LE, Chen X, Greaves SC: Entrapment of mitral chordal apparatus causing early postoperative dysfunction of a St. Jude mitral prosthesis. J Am Soc Echocardiogr 15:843-844, 2002 2. Gallet B, Berrebi A, Grinda JM, et al: Severe intermittent intraprosthetic regurgitation after mitral valve replacement with subvalvular preservation. J Am Soc Echocardiogr 14:314-316, 2001 3. Borowski A, Reiss N, Klaer R: Intermittent obstruction of the omnicarbon-valve prosthesis in the mitral position due to interference by papillary muscle. Diagnostic and surgical considerations. J Cardiovasc Surg (Torino) 33:305-307, 1992 4. Fasol R, Lakew F: Early failure of bioprosthesis by preserved mitral leaflets. Ann Thorac Surg 70:653-654, 2000 5. Neville PH, Aupart MR, Diemont FF, et al: Carpentier-Edwards pericardial bioprosthesis in aortic or mitral position: A 12-year experience. Ann Thorac Surg 66:S143-S147, 1998 (suppl) 6. Poirer NC, Pelletier LC, Pellerin M, et al: Fifteen-year experience with the Carpentier-Edwards pericardial prosthesis. Ann Thorac Surg 66:S57-S61, 1998 7. Ionescu AA, West RR, Proudman C, et al: Prospective study of routine perioperative transesophageal echocardiography for elective valve replacement: Clinical impact and cost-saving implications. J Am Soc Echocardiogr 14:659-667, 2001 8. Muratori M, Berti M, Doria E, et al: Transesophageal echocardiography as predictor of mitral valve repair. J Heart Valve Dis 10:65-71, 2001
9. Omran AS, Woo A, David TE, et al: Intraoperative transesophageal echocardiography accurately predicts mitral valve anatomy and suitability of repair. J Am Soc Echocardiogr 15:950-957, 2002 10. Fujii H, Suehiro S, Shibata T, et al: Value of intraoperative transesophageal echocardiography in preventing serious complications during valvular surgery. A report of four cases. J Heart Valve Dis 11:135-138, 2002 11. Practice Guidelines for Perioperative Transesophageal Echocardiography: A report by the American Society of Anesthesiologists and the Society of Cardiovascular Anesthesiologists Task Force on transesophageal echocardiography. Anesthesiology 84:986-1006, 1996 12. C-E Perimount Pericardial Mitral Bioprosthesis [package insert]. Edwards Lifesciences in collaboration with Vincent L. Sorrell, James D. Thomas: Recognizing normal flow patterns and anomalies on TEE. Echocardiographic assessment of the Carpentier-Edwards PERIMOUNT pericardial mitral bioprosthesis. Irvine, CA, Edwards Lifesciences, 2002 13. Abe M, Sakai A, Hanayama N, et al: Reoperation for malfunction of Ionescu-Shiley bovine pericardial bioprosthetic valves in the mitral position—special consideration with emergency operation. Nippon Kyobu Geka Gakkai Zasshi 45:17-22, 1997 14. Grabenwoger M., Grimm M, Leukauf C, et al: Failure mode of new pericardial valve prosthesis (Sorin Pericarbon). A morphological study. Eur J Cardiothorac Surg 8:470-476, 1994 15. Leandri J, Bertrand P, Mazzucotelli JP, et al: Mode of failure of the Mitroflow pericardial valve. J Heart Valve Dis 1:225-231, 1992
F
AILURE OF bioprosthetic valves implanted in the mitral position may occur months or years after the procedure because of a myriad of reasons. The authors present a case of intraoperative failure of a newly placed Carpentier-Edwards (Irvine, CA) bioprosthesis that was rapidly diagnosed by a transesophageal echocardiographic (TEE) examination. CASE REPORT An 81-year-old woman with coronary artery disease, hypertension, type 2 diabetes mellitus, and congestive heart failure (New York Heart Association class III) was admitted to the hospital with a history of lightheadedness and dyspnea. Cardiac catheterization showed severe triple-vessel coronary artery disease with complete occlusion of the left anterior descending, circumflex, and right coronary arteries. A TEE examination revealed severe mitral annulus calcification, severe mitral regurgitation, mild aortic stenosis, mild aortic insufficiency, and a normal ejection fraction. She was scheduled for an elective coronary artery bypass graft surgery operation with a mitral valve replacement under general anesthesia with standard and invasive monitoring including an arterial catheter, pulmonary artery catheter, and transesophageal echocardiogram. The operative approach included a sternotomy, bicaval cannulation, and retrograde cardioplegia. The patient first underwent coronary artery bypass graft surgery of her left anterior descending, first marginal, and second marginal arteries with no complications. The mitral valve was exposed through a left atriotomy revealing degenerated valve leaflets and severe annulus calcification. After the annulus was debrided, the anterior leaflet was excised, and the mitral orifice was sized for a no. 27-mm stented Carpentier-Edwards pericardial prosthesis (model #6900). Pledgeted annular sutures were placed through the sewing ring, but the valve did not seat properly because of extensive annular calcification. On testing the valve with an intraventricular saline injection, it was noted to be centrally incompetent without evidence of leaflet trapping. The prosthetic valve was removed, the annulus was debrided, and a second larger stented pericardial prosthesis (29-mm; Edwards Lifesciences, Irvine, CA) was seated and sutured with no difficulty. After atrial closure, air was evacuated from the heart and the patient
Fig 2. Intraoperative TEE revealing severe mitral regurgitation after valve replacement with Carpentier-Edwards pericardial bioprosthesis.
rewarmed to discontinue cardiopulmonary bypass (CPB). At this time, TEE examination of the heart revealed severe mitral insufficiency with total failure of the prosthetic valve leaflets to coapt with each other (Figs 1 and 2). The patient was recooled to 30°C and cardioplegic arrest repeated. Examination of the valve revealed severe tethering of leaflets as a result of a structural defect (Figs 3 and 4). The subvalvular area did not show any retraction of valve leaflets with suture. Retesting of the valve after pledgets and sutures were removed still showed significant tethering and insufficiency. The valve was replaced by a stented porcine xenograft (29-mm Mosaic; Medtronic, Minneapolis, MN). The patient was weaned from CPB again after a total of 314 minutes and cross-clamp times of 136 ⫹ 95 minutes. A postbypass transesophageal echocardiogram revealed good valve function along with hypokinetic inferior and posterior myocardium. The patient had a complicated postoperative course including hemiparesis and a sternal wound infection and expired after 6 months. DISCUSSION
The most common cause of intraoperative prosthetic valve failure is severe paravalvular leak. Mechanical or prosthetic valve failure occurring days or months after implantation has been reported in the literature,1,2 but immediate failure because of a valve defect is rare. Late failures are attributed to technical problems (residual para-annular tissue, entrapment of mitral
Fig 1. Intraoperative TEE showing failure of newly implanted mitral prosthesis valve leaflets to coapt.
From the *Department of Anesthesia, Children’s Hospital Boston, Boston, MA; and †Department of Anesthesia, Division of Cardiothoracic Anesthesia, New York University School of Medicine, New York, NY. Address reprint requests to Mamta Thukral, MD, Children’s Hospital Boston, 300 Longwood Avenue, Boston, MA 02115. E-mail: [email protected] © 2007 Elsevier Inc. All rights reserved. 1053-0770/07/2101-0019$32.00/0 doi:10.1053/j.jvca.2005.09.003 Key words: prosthetic mitral valve, transesophageal echocardiogram, intraoperative valve failure, cardiac surgery
Journal of Cardiothoracic and Vascular Anesthesia, Vol 21, No 1 (February), 2007: pp 93-95
93
94
THUKRAL AND KANCHUGER
Fig 3. Structural defects seen in explanted mitral pericardial bioprosthesis that resulted in severe regurgitation intraoperatively. (Color version of figure is available online.)
Fig 5. Normally functioning Carpentier-Edwards mitral bioprosthesis will usually show mild central regurgitation and one or more jets along the stent posts. (Color version of figure is available online.)
chordal apparatus, thrombus, suture loops, or excessively long suture tails) or unusual postoperative complications.3,4 Studies on Carpentier-Edwards pericardial prosthetic valves have revealed excellent long-term results with few early postoperative failures, but no reported intraoperative problems.5,6 To the authors’ knowledge, this is the only reported case of acute valve failure occurring because of tethering of valve leaflets that was detected before the patient was taken off CPB. Studies have indicated that routine intraoperative TEE examination is not only clinically beneficial in patients undergoing valvular surgery, but is also cost-effective in tertiary care centers.7 A transesophageal echocardiogram provides a powerful means to define the mechanisms of mitral regurgitation and identify the suitability of patients for valvuloplasty.8-10 A routine TEE examination after valve replacement allows visualization and assessment for structural abnormalities, transvalvular flow, paravalvular leaks, and regurgitation.11 The echocardiographer must be aware of signature flow patterns of
normally functioning prosthetic valves. Because of its basic design, the Carpentier-Edwards pericardial valve shows traceto-mild central regurgitation and one or more jets along the coaptation edge of the leaflets12 (Fig 5). This finding may not be seen on a postoperative transthoracic echocardiogram, but is usually benign and expected to continue for the duration of the valve. Leakage through the cloth portion of the valve (Fig 6) may also be seen but, unlike signature flow patterns, is usually temporary and disappears intraoperatively after giving protamine. Significant abnormal findings include moderate-to-severe central regurgitation, large paravalvular leaks, eccentric jets, suboptimal coaptation of valve leaflets, and interference of valve function by subvalvular apparatus. In addition, a risk for all stented valves is strut entrapment by suture loops or subvalvular apparatus, restricting leaflet movement and resulting in moderate-to-severe regurgitation. TEE interpretations are operator-dependent and subject to variability because of instru-
Fig 4. The valve leaflets of the explanted pericardial mitral valve show severe tethering. (Color version of figure is available online.)
Fig 6. Leakage through cloth portion of the valve may temporarily result in one or more trivial jets of mitral regurgitation. (Color version of figure is available online.)
PERICARDIAL MITRAL VALVE
95
ment settings (probe position, orientation, and gain) and patient factors (volume status, blood pressure, and presence of echo window), necessitating a careful and thorough examination to detect potentially disastrous situations. The intraoperative transesophageal echocardiogram is a powerful tool and provides high-resolution analysis of most intracardiac pathologies. Early failure of pericardial prosthetic valves can have several mechanisms. In a case series, 35 of 68 patients undergoing mitral valve replacements with the Ionescu-Shiley (Pfizer Inc, New York, NY) bovine pericardial prosthesis required reoperation because of primary tissue failure of bioprosthesis.13 Cusp tears, which were considered the dominant cause of sudden and progressive valve failure, were observed in all of the valves. This pointed to faulty valve mechanics and engineering. Another study reported failure of the Sorin-Pericarbon (Sorin Biomedica Cardio S.p.A., Via Crescentino, Italy) pericardial valve (aortic and mitral) prostheses in 10 of 144 patients, primarily because of early valvular stenosis (7/10 valves) that was caused by severe calcification of commissural as well
as basal regions of the valve leaflets.14 Cusp tearing was observed in only 2 cases. A consecutive series studying the Mitroflow (Sorin Group Canada, Inc, Burnaby, BC, Canada) pericardial bioprostheses, inserted in the mitral and aortic positions, revealed valve failures primarily because of collagen degeneration that was seen in all explanted valves.15 The areas of tissue degeneration were the major sites of calcification in the valves, which led to questions about the adequacy of the methods used in valve harvesting, processing, and glutaraldehyde preservation. In the present case, intraoperative valve failure was postulated to be caused by suture entrapment around the valve struts as a result of valve design. Entrapment can occur in Carpentier-Edwards bovine mitral pericardial prosthesis because of low-profile valve struts, and can be difficult to diagnose after the valve is seated in place. Hopefully, modifications are being made in the valve design to overcome this problem.
REFERENCES 1. Thomson LE, Chen X, Greaves SC: Entrapment of mitral chordal apparatus causing early postoperative dysfunction of a St. Jude mitral prosthesis. J Am Soc Echocardiogr 15:843-844, 2002 2. Gallet B, Berrebi A, Grinda JM, et al: Severe intermittent intraprosthetic regurgitation after mitral valve replacement with subvalvular preservation. J Am Soc Echocardiogr 14:314-316, 2001 3. Borowski A, Reiss N, Klaer R: Intermittent obstruction of the omnicarbon-valve prosthesis in the mitral position due to interference by papillary muscle. Diagnostic and surgical considerations. J Cardiovasc Surg (Torino) 33:305-307, 1992 4. Fasol R, Lakew F: Early failure of bioprosthesis by preserved mitral leaflets. Ann Thorac Surg 70:653-654, 2000 5. Neville PH, Aupart MR, Diemont FF, et al: Carpentier-Edwards pericardial bioprosthesis in aortic or mitral position: A 12-year experience. Ann Thorac Surg 66:S143-S147, 1998 (suppl) 6. Poirer NC, Pelletier LC, Pellerin M, et al: Fifteen-year experience with the Carpentier-Edwards pericardial prosthesis. Ann Thorac Surg 66:S57-S61, 1998 7. Ionescu AA, West RR, Proudman C, et al: Prospective study of routine perioperative transesophageal echocardiography for elective valve replacement: Clinical impact and cost-saving implications. J Am Soc Echocardiogr 14:659-667, 2001 8. Muratori M, Berti M, Doria E, et al: Transesophageal echocardiography as predictor of mitral valve repair. J Heart Valve Dis 10:65-71, 2001
9. Omran AS, Woo A, David TE, et al: Intraoperative transesophageal echocardiography accurately predicts mitral valve anatomy and suitability of repair. J Am Soc Echocardiogr 15:950-957, 2002 10. Fujii H, Suehiro S, Shibata T, et al: Value of intraoperative transesophageal echocardiography in preventing serious complications during valvular surgery. A report of four cases. J Heart Valve Dis 11:135-138, 2002 11. Practice Guidelines for Perioperative Transesophageal Echocardiography: A report by the American Society of Anesthesiologists and the Society of Cardiovascular Anesthesiologists Task Force on transesophageal echocardiography. Anesthesiology 84:986-1006, 1996 12. C-E Perimount Pericardial Mitral Bioprosthesis [package insert]. Edwards Lifesciences in collaboration with Vincent L. Sorrell, James D. Thomas: Recognizing normal flow patterns and anomalies on TEE. Echocardiographic assessment of the Carpentier-Edwards PERIMOUNT pericardial mitral bioprosthesis. Irvine, CA, Edwards Lifesciences, 2002 13. Abe M, Sakai A, Hanayama N, et al: Reoperation for malfunction of Ionescu-Shiley bovine pericardial bioprosthetic valves in the mitral position—special consideration with emergency operation. Nippon Kyobu Geka Gakkai Zasshi 45:17-22, 1997 14. Grabenwoger M., Grimm M, Leukauf C, et al: Failure mode of new pericardial valve prosthesis (Sorin Pericarbon). A morphological study. Eur J Cardiothorac Surg 8:470-476, 1994 15. Leandri J, Bertrand P, Mazzucotelli JP, et al: Mode of failure of the Mitroflow pericardial valve. J Heart Valve Dis 1:225-231, 1992