Ann Thorac Surg 2002;73:965-967
© 2002 The Society of Thoracic Surgeons
Case report
Replacement of a thrombosed valve after the Bentall procedure
Hideyuki Harada, MD*a,
Toshiro Ito, MDa,
Tohru Mawatari, MDa,
Tomio Abe, MDb
a Department of Thoracic and Cardiovascular Surgery, Hokkaido Prefectural Kushiro Hospital, Kushiro, Japan
b Department of Thoracic and Cardiovascular Surgery, Sapporo Medical University of Medicine, Sapporo, Japan
Accepted for publication June 13, 2001.
* Address reprint requests to Dr Harada, Department of Thoracic and Cardiovascular Surgery, Hokkaido Prefectural Kushiro Hospital, 1-4-26 Sakuragaoka, Kushiro-shi, Hokkaido 085-0805, Japan
e-mail: hideyuki.harada{at}pref.hokkaido.jp
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Abstract
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A 50-year-old man developed thrombosis in the valve of a Björk-Shiley prosthesis that had been used for composite graft replacement of the aortic valve and ascending aorta 8 years previously. The thrombosed valve was removed, and because of the narrow aortic valve ring, it was replaced using patch enlargement of the aortic annulus without replacement of the conduit.
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Introduction
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Thrombosis in a valve after the Bentall procedure presents a particularly challenging situation for cardiothoracic surgeons. We report such a case in which the valvular prosthesis was removed and replaced using patch enlargement of the aortic annulus without replacement of the conduit.
A 50-year-old man underwent the Bentall procedure in April 1988, receiving a composite Dacron (DuPont, Wilmington, DE) graft with a 27-mm Björk-Shiley prosthesis because of annuloaortic ectasia with severe aortic regurgitation. The patient did well and was adequately anticoagulated with warfarin until 8 years later, when he developed sudden onset of dyspnea, orthopnea, and bloody sputum. No sounds were heard from the prosthetic valve, and an aortic systodiastolic murmur was present. Following admission to the hospital, a cinefluoroscopic examination demonstrated that the valve disc opened to only 38 degrees and closed to only 24 degrees, although a normal one opens to 60 degrees and closes to 0 degrees (Fig 1),
and echocardiography showed severe aortic regurgitation, with a measured transprosthetic valve gradient of 100 mm Hg. Because 2-day thrombolytic therapy was not effective, surgical intervention was indicated.
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Fig 1. Cinefluoroscopic view of the Björk-Shiley aortic valve prosthesis at the time of thrombosis; note the restricted motion of the valve opening (A) in systole and (B) in diastole.
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At the time of the operation, cardiopulmonary bypass was conducted with femoral and right atrial cannulation. The ascending aorta was cross-clamped, and antegrade and retrograde cold blood cardioplegia was instituted. The aorta was opened through the graft (Fig 2), and the coronary anastomoses were found to be clearly patent. The prosthesis was occluded by an organized thrombus, which formed a pannus over the annulus and extended into the minor and major orifices and on the aortic and ventricular sides, restricting the motion of the disc. The thrombosed prosthesis was extirpated, leaving the aortic graft intact. The valve annulus was small because of pannus formation on the ventricular side. Because the valve annulus was sized to 21 mm, which was considered suboptimal, the graft incision was extended through the annulus in the noncoronary cusp and carried onto the anterior leaflet of the mitral valve [1]. A fusiform Gelseal (Sulzer Vascutek Ltd, Renfrewshire, Scotland) Dacron patch was sutured to the V-shaped defect in the anterior mitral leaflet and aortic root with running suture lines. A 23-mm St. Jude Medical prosthesis (St. Jude Medical, St. Paul, MN) was then implanted using mattress sutures, starting from the ventricular side of the aortic annulus, through the aortic graft, and then through the sewing ring of the valve. In the area of the patch, pledgeted mattress sutures were placed from outside the patch through the sewing ring of the valve. The aorta was then closed, incorporating the Dacron patch. The total cardiopulmonary bypass time was 174 minutes, and the aortic cross-clamp time was 151 minutes. The patient was weaned from bypass without difficulty, and the postoperative course was uncomplicated. Postoperative aortography revealed smooth blood flow and valve motion in the ascending aorta. The patient was discharged and has continued to do well on adequate antithrombotic therapy.
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Comment
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The Bentall procedure is well accepted for the management of patients with aortic root disease. In those who have received a tissue prosthesis, however, reoperation is very likely, as the prosthesis degenerates over time [2, 3]. Reoperation for a thrombosed valve after the Bentall procedure is truly rare, with only two cases cited in the review by Kouchoukos and colleagues [4]. A matter of concern with the Björk-Shiley valve is sudden thrombosis in patients who have apparently received inadequate anticoagulation therapy, the reported incidence being 0.05% per patient-year for the aortic position [5]. Although our patient’s dose of warfarin had been appropriate, thrombotic interference with the action of the prosthesis occurred. When thrombolytic treatment is not effective, replacement of the prosthesis and thrombectomy are the two currently available options. During the operation in the present case, because a pannus was found in addition to the thrombus, the prosthesis was removed and replaced without replacement of the conduit, because in this setting, removal of the entire graft and reinsertion of a new composite graft carry serious risks.
Carrel and associates [6] reported that patients with a 21-mm standard St. Jude Medical valve had higher mean and maximal pressure gradients than patients with a 23-mm standard St. Jude Medical valve. Moreover, because of the high (100 mm Hg) aortic valve pressure gradient before the operation, we considered that the larger valve would provide a lower pressure gradient after the operation. Annuloplasty allowed the aortic prosthesis to be enlarged from 21 mm to 23 mm. The technique used here is invasive to the mitral valve, but simple and useful. In our patient, no impairment of mitral valve function was detectable. Although strict antithrombotic therapy will be necessary, the St. Jude Medical valve is expected to give good long-term results because of its excellent durability, thromboresistance, and hemodynamic performance [7].
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References
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Nicks R., Cartmill T., Bernstein L. Hypoplasia of the aortic root: the problem of aortic valve replacement. Thorax 1970;25:339-346.[Abstract/Free Full Text]
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Panos A.L., Teoh K.T., Wilson J.K., Salerno T.A. Replacement of the valvular prosthesis in a patient with a Bentall procedure. Ann Thorac Surg 1992;54:555-556.[Abstract]
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Kouchoukos N.T., Marshall W.G., Jr, Wedige-Stecher T.A. Eleven-year experience with composite graft replacement of the ascending aorta and aortic valve. J Thorac Cardiovasc Surg 1986;92:691-705.[Abstract]
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Venugopal P., Kaul U., Iyer K.S., et al. Fate of thrombectomized Björk-Shiley valves. J Thorac Cardiovasc Surg 1986;91:168-173.[Abstract]
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Carrel T., Zingg U., Jenni R., Aeschbacher B., Turina M.I. Early in vivo experience with the Hemodynamic Plus St. Jude Medical heart valves in patients with narrowed aortic annulus. Ann Thorac Surg 1996;61:1418-1422.[Abstract/Free Full Text]
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Baudet E.M., Puel V., McBride J.T., et al. Long-term results of valve replacement with the St. Jude Medical prosthesis. J Thorac Cardiovasc Surg 1995;109:858-870.[Abstract]
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Abstract
Introduction
