Ann Thorac Surg 2005;79:1480-1485
© 2005 The Society of Thoracic Surgeons
Original articles: Cardiovascular
Aortic Valve Periprosthetic Leakage: Anatomic Observations and Surgical Results
Giuseppe De Cicco, MDa,*,
Roberto Lorusso, MD, PhDa,
Andrea Colli, MDb,
Francesco Nicolini, MDb,
Claudio Fragnito, MDb,
Teresa Grimaldi, MDc,
Bruno Borrello, MDb,
Alessandro Maria Budillon, MDb,
Tiziano Gherli, MDb,
Cesare Beghi, MDb
a Cardiac Surgery Unit, Civic Hospital, Brescia, Italy
b Department of Cardiac Surgery, University of Parma, Parma, Italy
c Department of Cardiology, University of Modena and Reggio Emilia, Modena, Italy
Accepted for publication November 17, 2004.
* Address reprint requests to Dr De Cicco, U.O. di Cardiochirurgia, Spedali Civili di Brescia, Piazzale Spedali Civili, 1-25125 Brescia, Italy (E-mail: giudeci{at}libero.it).
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Abstract
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BACKGROUND: One of the most frequent causes of reoperation after heart valve replacement is periprosthetic leakage (PPL). Previous studies have failed to determine whether PPL is linked to specific anatomic details. The aim of this study was to examine the location within the aortic annulus where PPL occurs, and to evaluate the postoperative outcome after surgical correction.
METHODS: Between January 1985 and December 2001, 28 patients underwent reoperation because of PPL after aortic valve replacement. The aortic annulus was analyzed in a clockwise format with hour 1 corresponding to the commissure between the left coronary sinus and the right coronary sinus, hour 5 to the commissure between the right coronary sinus and the noncoronary sinus, and hour 9 to the commissure between the noncoronary sinus and the left coronary sinus.
RESULTS: Overall operative mortality was 7.1% (2 patients). Repair of PPL was carried out in 8 patients whereas prosthetic valve replacement was necessary in 20 patients. Urgency or emergency operation (p < 0.0037), preoperative New York Heart Association class IV (p < 0.04), need for prosthetic valve replacement (p = 0.05), and implant of mechanical valve (p = 0.031) were independent determinants of dismal prognosis. Periprosthetic leakage occurred more frequently between hour 4 and hour 8 (19 patients), with the risk of leakage being two times greater than in other annular areas.
CONCLUSIONS: Our study suggests that PPL occurs more frequently in a specific portion of the peculiar aortic annulus. In case of PPL diagnosis, a timely reoperation might decrease operative risks by avoiding emergency procedures and unfavorable preoperative clinical conditions, and preventing prosthetic valve replacement.
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Introduction
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The continuous improvements in the field of cardiac valve prosthesis have led to more hemodynamically efficient artificial heart valves. However, prosthetic valve implantation is still not completely free of complications, mainly owing to prosthetic dysfunction. One of the most frequent causes of reoperation in this context is periprosthetic leakage (PPL). Periprosthetic leakage occurs in 1% to 3.5% of patients after aortic valve replacement (AVR) [1]. Factors predisposing to PPL have not been fully identified, although some conditions may represent negative determinants for postoperative prosthetic valve function [1]. Anatomic factors have been poorly investigated or considered not critical for an adverse event of this kind [1–4]. The aortic annulus is not a ringlike structure supporting the valve leaflets. Indeed, the leaflets are attached in a semilunar fashion that allows the cusps to open properly during ventricular systole [5]. The difference between the surgical and anatomic annulus is striking, because prosthetic aortic valve implantation, with the majority of the current prostheses, modifies the semilunar line of the leaflet attachment toward a monoplanar circular shape. Aortic root anatomy and shape, and ventricular outflow tract interaction, are all well-established factors for hemodynamically effective blood flow [6]. However, surgically induced anatomic changes of these factors might expose untrained or weak anatomic structures to excessive or abnormal pressure forces, with subsequent unprotected or intolerable tractions. These hemodynamic and anatomic conditions may ultimately lead to PPL after AVR, also enhanced by the pulsatility or rigidity mismatch of the prosthetic ring and aortic wall relationship [7]. Only a few papers have analyzed the incidence of PPL and postoperative results after AVR, but no specific attention has been paid to the potential relationship between anatomic factors and PPL occurrence. Our retrospective study, therefore, evaluated our experience in patients undergoing reoperation for aortic valve PPL and focused data interpretation on anatomic–surgical details to assess reoperation results as well as outcome predictors.
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Material and Methods
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From January 1985 to December 2001, in a clinical series of 1,696 patients who had undergone AVR, reoperation was performed in 175 patients (10.3%). Mean time elapsed from surgery to redo operation was 67.13 ± 11.8 months (range, 7 days to 12 years). Periprosthetic leakage occurred in 39 patients (2.3%) and represented the second most frequent cause of reoperation. Excluding criteria for study enrollment were the presence of a stentless bioprosthesis, the diagnosis of an active or previous endocarditis on native aortic valve or valve prosthesis, Marfan syndrome, and valve replacement on a bicuspid aortic valve. The diagnosis of endocarditis was made through the presence of fever, positive blood cultures, and vegetations observed at transthoracic echocardiography and intraoperative inspection or at pathologic assessment. Only 28 patients met the inclusion criteria of the study. The follow-up was conducted according to the criteria set out by Edmunds and colleagues [8]. Patients' demographics and preoperative conditions are shown in Table 1.
Surgical Technique and Intraoperative and Postoperative Assessment
A median sternotomy was performed in all cases. Cardiopulmonary bypass was performed in 26 patients with aortic and right atrial cannulas, whereas in 2 patients femoral vessel cannulation was carried out. Cardiopulmonary bypass was instituted at mild hypothermia (range, 22° to 32°C), and myocardial protection was achieved with antegrade cold intermittent blood cardioplegia in 23 patients whereas retrograde cold crystalloid cardioplegia was used in 5 patients.
From 1985 until 1995, patients were assessed after AVR only with transthoracic echocardiography before hospital discharge, whereas from 1996 transesophageal echocardiography was instituted intraoperatively and transthoracic echocardiography was also carried out before hospital discharge. In 1 patient, in the series before the advent of intraoperative transesophageal echocardiography, postoperative transthoracic echocardiography showed PPL a few days after AVR, which was immediately corrected. No further patients had any evidence of PPL (trivial or more severe) either intraoperatively or postoperatively, although the absence of transesophageal echocardiography in the patient series from 1985 to 1995 cannot definitely exclude PPL undetectable by transthoracic echocardiography before hospital discharge.
Anatomic–Surgical Study
The anatomic–surgical study was performed by analyzing the aortic annulus in a clockwise format, indicating the situs of leakage by means of the corresponding hour. Hour 1 was assigned to the commissure between the left coronary sinus and the right coronary sinus, hour 5 was assigned to the commissure between the right coronary sinus and the noncoronary sinus, and hour 9 to the commissure between the noncoronary sinus and the left coronary sinus. This representation of the aortic annulus was adopted by modifying the description of Sud and collaborators [9] (Fig 1).
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Fig 1. Partition of aortic annulus adopting a clock format. (LCS = left coronary sinus; NCS = noncoronary sinus; RCS = right coronary sinus.)
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Statistical Analysis
Data were evaluated by computing means and percentages ± standard deviation. The influence of various preoperative variables on operative mortality was assessed by univariate analysis with p values considered significant when 0.05 or less. The analysis of categorical variables was performed using the 
2 test and the two-sided Fisher's exact test, when appropriate. Operative mortality included both operative and hospital deaths. Actuarial estimates were calculated using the Kaplan-Meier method. The comparisons were made using log-rank statistics and were considered significant when values were 0.05 or less. All statistical procedures were performed using SPSS 8.0 (SPSS, Inc, Chicago, IL).
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Results
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The overall surgical mortality was 7.1% (2 patients); all deaths occurred intraoperatively (low cardiac output syndrome). These 2 patients were operated on under urgency or emergency conditions and were in New York Heart Association class IV.
In 20 patients a prosthesis replacement was performed: 12 patients had a mechanical prosthesis and 8 patients had a bioprosthesis. Prosthesis replacement was carried out using horizontal mattress sutures of 2-0 Ethibond (Ethicon, Somerville, NJ) buttressed with polytetrafluoroethylene (Teflon) felt pledgets, leaving the pledgets on the ventricular side in 8 patients and on the aortic side in 12 patients. Repair of the PPL was performed in 8 patients: in 5 patients using horizontal mattress sutures through the prosthetic sewing ring and through the aortic wall with the sutures tied outside the aorta over a felt pledget as shown by Girardet and colleagues [10], whereas in 3 patients horizontal mattress sutures passing through the aortic annulus and the sewing ring were used as described by Björk [11]. There were 1 early (30 days) and 9 late deaths among patients who underwent prosthesis replacement. All deaths were cardiac related [8]. In the repair group there were 1 early (low cardiac output syndrome) and 1 late non–cardiac-related death (gastric neoplasia).
Concomitant procedures performed included one mitral valve repair, one mitral valve replacement and tricuspid valve repair, one mitral-aortic continuity repair, and two coronary aortic bypass graftings.
Reoperation for postoperative bleeding occurred in 5 patients (17.8%). Acute renal failure occurred in 2 patients (7.1%), and postoperative minor neurologic complications accounted for 3 patients (10.7%).
The location and the extent of PPL at the aortic annulus are shown in Figure 2. The incidence of PPL was clearly more frequent between hour 4 and hour 8, although in some cases PPL involved more than one annular sector. The ratio of the observed PPL occurrence, as compared with a theoretic ubiquitous PPL, is illustrated in Table 2, clearly indicating the increased risk of PPL in a determined portion of the annulus, which corresponds to a peculiar anatomic relationship and structures, as shown in Figure 3.
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Fig 2. Location and extent of periprosthetic leakage. Cases with leakage into the sector between hour 4 and hour 8 (n = 19). Cases with leakage into the sector between hour 8 and hour 4 (n = 20). (LCS = left coronary sinus; NCS = noncoronary sinus; RCS = right coronary sinus.)
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Fig 3. Relationship between the sector of periprosthetic leakage occurrence and the anatomy of the aortic annulus. (LCS = left coronary sinus; LVB = lateral aspect of left ventricular base; Me-Mu = muscular-membranous part of septum; Mu = muscular part of septum; MVAL = mitral valve anterior leaflet; NCS = noncoronary sinus; RCS = right coronary sinus.) (Modified from Sud A, et al, Ann Thorac Surg; 1984;38:76–9 [9], with permission.)
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With regard to the postoperative results of PPL correction, actuarial survival is shown in Figure 4. Analysis of postoperative predictors showed that preoperative conditions affected the postoperative outcome, as shown in Tables 3 and 4. The type of surgical strategy also influenced the late prognosis, as the need for a prosthesis replacement instead of PPL repair or the use of a mechanical valve instead of a bioprosthesis led to a worse outcome (Fig 5).
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Fig 5. Adjusted Kaplan-Meier survival in patients (excluding operative deaths). (A) Periprosthetic leakage repair and prostheses replacement. (B) Mechanical prostheses and bioprostheses replacement. (pz = patients.)
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Comment
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Periprosthetic leakage is a frequent cause of reoperation after AVR, and in our series represented the second most frequent indication for repeated surgery, the first cause being the degeneration of biologic prosthetic valves [12]. These findings are in accordance with previous reports, which have shown PPL to occur in 1% to 3.5% of AVR procedures [1].
Prosthetic endocarditis, Marfan syndrome, bicuspid aorta, and severely calcified aortic annulus are all factors claimed to predispose for PPL or be directly connected to its occurrence [13–18]. Anatomic factors have not been shown to be linked to postoperative PPL. In previous studies the distribution of PPL was shown to be ubiquitous around the aortic annulus or was not specifically investigated [1–4]. In our study the highest rate of PPL was detected between hour 4 and hour 8 of the aortic annulus analyzed in a clockwise format, that is between the middle of the right coronary sinus and the middle of the noncoronary sinus annulus. Our data showed a double risk of presentation of PPL in that sector. The annular portion between hour 4 and hour 8 corresponds to the area above the membranous part of the interventricular septum and the right trigone of the cardiac skeleton and basically includes the area of attachment of the noncoronary cusp [9]. The embryologic origin of this leaflet and its portion of the aortic annulus could be a reason for its intrinsic weakness. The right and the left cusps originate respectively from the right superior truncoconal cushion and the left inferior truncoconal cushion and are specializations of the split lateral tubercles of the right and left truncoconal wall [19]. In contrast, the noncoronary cusp derives from the intercalated endocardial cushion that covers a minor tubercle of the posterior truncoconal wall [20]. The cells of this tubercle migrate inside an area of tissue constituted by the superior endocardial cushion and form the noncoronary cusp, the respective sector of the aortic annulus and the homologous sinus of Valsalva by an excavation process common to the other cusps [19].
The intrinsic anatomic weakness of this part of the annulus might be explained by additional factors. Thubrikar and colleagues [7] analyzed the aortic root in an animal model and showed that the base of the right and left coronary leaflets is encompassed by myocardium, whereas the base of the noncoronary leaflet does not appear to be embedded in the ventricular muscle and its base seems to be higher in the aortic root plane. This makes the base of the aortic valve capable of cyclic dimensional changes. Its perimeter is maximal in early systole (isovolumetric contraction), decreases during systolic ejection, and increases again during diastole [7]. Thubrikar and coworkers [7] concluded that the mismatch between the nonexpansible sewing ring of the aortic prostheses and the normally expansive base of the valve could cause occasional PPL. Thubrikar and associates [7] do not describe a difference in the behavior of the bases of the three leaflets. However, the lack of muscular tissue at the base of the noncoronary leaflet presumes that this sector has hypodynamic properties, transforming it into a point of anchorage thanks to the greater dynamic energy developed by the other two bases. This could increase the stress at the base of the noncoronary leaflet, transforming it into a major site of PPL development. This hypothesis is confirmed by Lansac and colleagues [21], who studied mechanical changes during the cardiac cycle, dividing the aortic base of the aortic root into three sectors starting from the lowest point of each of the right, left, and noncoronary sinuses of Valsalva. They found different dynamic characteristics among the three lengths, with the segment between the lowest point of the right coronary sinus and the noncoronary sinus having the least expansion. This annular segment, according to our partition of the aortic annulus, corresponds to the sector between hour 4 and hour 8 found in our study to be the area most prone to develop PPL.
In terms of clinical issues, PPL may lead to hemodynamic, hematologic, or other clinical problems. More than mild periprosthetic regurgitation, presence of hemolysis, and impairment of global left ventricular function are standard indications for surgical reintervention [22]. Operative risk is higher than first-time surgery: in our series hospital death occurred in 7% of the total patient population, which is in accordance with most recent published reports indicating a hospital mortality ranging from 5.4% to 16% [22–24]. Several predictors have been shown to affect postoperative results, namely New York Heart Association class and emergency or urgency of reoperation [25–29]. Our data analysis confirmed that patients presenting for surgery for PPL in severe hemodynamic compromise have a worse prognosis. However, our findings indicated that additional factors like the type of PPL treatment and of prosthesis implanted were negative predictors of postoperative outcome, suggesting that timely and appropriate surgical intervention may enhance patient prognosis.
In conclusion, PPL represents a rare complication in the context of ordinary AVR. Apart from well-known predisposing factors, predominantly related to the etiology of the aortic valve disease, our study indicates that PPL may develop more frequently in some segments of the aortic annulus, and this information may call for adjunctive care when performing suture placement during AVR. Furthermore, delayed surgical correction of PPL, potentially leading to deterioration of patients' clinical conditions, should be avoided because suboptimal patient status before surgery was clearly linked to unfavorable postoperative prognosis.
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Acknowledgments
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The authors thank Barbara Di Fiore for her assistance.
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Abstract
Introduction
