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Ann Thorac Surg 2000;70:653-654
© 2000 The Society of Thoracic Surgeons

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Case report

Early failure of bioprosthesis by preserved mitral leaflets

^a Herz- und Gefaess-Klinik GmbH, Bad Neustadt/Saale, Germany

Address reprint requests to Dr Fasol, International "Innovative Medical Care" Center, Krems, Austria, Kreutzgasse 70/32, A-1180 Vienna, Austria
e-mail: rfasol{at}heart-surgeon.com

	Abstract

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Complete preservation of the posterior mitral valve leaflet caused early thrombotic occlusion of two cusps of a Carpentier-Edward pericardial prosthesis implanted into the mitral position with subsequent bioprosthetic failure, necessitating reoperation.

	Introduction

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The importance of the subvalvular apparatus and the preservation of the annuloventricular continuity in mitral valve replacement (MVR) surgery has been discussed for many years. Originally suggested by Lillehei, Levy, and Bonnabeau in 1964 [1] the preservation of the subvalvular apparatus has been shown experimentally and clinically to be superior to standard valve replacement procedures with chordal resection [2]. It has been suggested by several researchers that preservation of the anterior and posterior leaflet is a safe procedure to implant tilting-disc or bileaflet prostheses [3]. Except for one described failure of a Hancock II bioprostheses by chordal entrapment 26 months after surgery [4], no concerns have been reported when a bioprosthesis was used.

A 69-year-old male patient with shortness of breath and symptoms of angina at rest was shown to have an ostial stenosis of the right and the left coronary artery, a left main stem stenosis in addition to multiple coronary artery lesions, as well as a 3+ mitral valve regurgitation. The ejection fraction was calculated as 28%. Preoperative echocardiography showed a dilatation of the mitral annulus, papillary muscle dysfunction, and restricted motion of the posterior leaflet. The patient underwent combined coronary artery bypass surgery with four grafts and MVR. The incompetent mitral valve, with slightly myxomatous leaflets showing a prolapse of all parts and thin and elongated chordae, was assessed as not being easily suitable for reconstruction due to multiple and complex lesions. It was considered to replace and not repair the valve because of the expected length of the procedure in combination with multiple coronary artery bypass grafting in a severely sick patient with poor left ventricular function. The anterior mitral valve leaflet was detached from the annulus and the leaflet was divided and trimmed into two islands of tissue with the attached underlying chordae tendineae. These islands of leaflet tissue were sutured into place using the pledget-reinforced sutures to implant the valve, using everting mattress sutures with pledgets on the ventricular side. The posterior leaflet was left undisturbed and a 31-mm Carpentier-Edward pericardial prosthesis (Baxter Healthcare Corp, Irvine, CA) was then secured in position in the usual fashion.

The immediate postoperative course was free of any complications and the patient recovered well. Follow-up echocardiogram at the time of the attempted discharge on postoperative day 8 showed the two posterior cusps nonmobile due to thrombi as well as a thrombus in the left ventricle, attached to the mitral valve bioprosthesis. Transesophageal echocardiography confirmed these findings and showed a mean mitral transvalvular gradient of 8.6 mm Hg and a peak transvalvular gradient of 15.6 mm Hg in addition to moderate mitral regurgitation.

At operation, the two posterior cusps were found to be stuffed with thrombi, entrapped and covered by remnants of the preserved posterior mitral valve leaflet (Fig 1). In addition, thrombi were found to be attached to the posterior leaflet and chordae tendineae. The bioprosthesis was explanted and replaced with a 31-mm Carpentier-Edward pericardial prosthesis (Baxter Healthcare Corp, Irvine, CA) after excision of the posterior leaflet and all chordae tendineae. Care was taken to remove all the thrombotic material as well.

View larger version (101K): [in this window] [in a new window]   Fig 1. Explanted bioprosthetic valve showing two cusps found to be stuffed with thrombi, caused by remnants of the preserved posterior mitral valve leaflet (A). Close-up view of the thrombosed cusps (B).

	Comment

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Significant reduction of the ejection fraction in patients after MVR surgery without preservation of the chordae tendineae was demonstrated to be due to several factors, such as decreased preload, increased afterload, or impaired contractile function, resulting in the interruption of ventricular–valvular interaction with a change in the loading condition [5]. Preservation of both the anterior and posterior mitral subvalvular apparatus in MVR surgery was demonstrated to play an important role in preserving left ventricular regional wall motion and global left ventricular function [2]. Furthermore, a dreaded complication of mitral valve surgery such as myocardial rupture may be prevented by maintaining the tethering effect of the intact subvalvular apparatus [6]. However, complications such as chordal entrapment of bioprosthesis [4] or intermittent obstructions of mechanical prosthesis have been reported [7], although these incidences seem to be extremely rare. Our experience with early thrombotic occlusion of two cusps of the implanted Carpentier-Edward pericardial prosthesis caused by remnants of the preserved posterior mitral valve leaflet may have been avoided if the posterior leaflet was also detached from the annulus and only islands of tissue with the attached underlying chordae tendineae were reimplanted. It may be assumed that turbulences caused by the posterior leaflet led to the formation of thrombi, subsequently causing the thrombotic occlusion of two cusps of the implanted bioprosthesis.

This report of our early complication is not intended to suggest abandoning this valuable technique of preservation of the annuloventricular continuity in MVR surgery, but rather to alert surgeons to rare but possible complications.

	References

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1. Lillehei C.W., Levy M.J., Bonnabeau R.C., Jr Mitral valve replacement with preservation of papillary muscles and chordae tendineae. J Thorac Cardiovasc Surg 1964;57:532-543.
2. Natsuaki M., Itoh T., Tomita S., et al. Importance of preserving the mitral subvalvular apparatus in mitral valve replacement. Ann Thorac Surg 1996;61:585-590.[Abstract/Free Full Text]
3. Choh J.H. Preservation of anterior and posterior leaflet in mitral valve replacement with a tilting-disc valve. Ann Thorac Surg 1997;64:271-273.[Abstract/Free Full Text]
4. Prabhakar G., Kumar N., Hatle L., Al-Halees Z., Duran C.M.G. Accelerated failure of bioprosthesis by entrapment in chordal-sparing mitral valve replacement. Ann Thorac Surg 1994;108:185-187.
5. Nakano K., Swindle M.M., Spinale F., et al. Depressed contractile function due to canine mitral regurgitation improves after correction of the volume overload. J Clin Invest 1991;87:2077-2086.
6. Okita Y., Miki S., Veda Y., Tahata T., Saki T., Matsugama K. Mitral valve replacement with maintenance of mitral annulopapillary muscle continuity in patients with mitral stenosis. J Thorac Cardiovasc Surg 1994;108:42-51.[Abstract/Free Full Text]
7. Borowski A., Reiss N., Klaer R. Intermittent obstruction of the Omnicarbon-valve prosthesis in the mitral position due to interference by papillary muscle. J Cardiovasc Surg 1992;33:305-307.[Medline]

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