Ann Thorac Surg 2006;81:1879-1880
© 2006 The Society of Thoracic Surgeons
Case report
Fracture of Colvin-Galloway Future Band Causing a Tear in the Anterior Mitral Leaflet
Martin Hartrumpf, MD
*
,
Ulrich A. Stock, MD, PhD,
Ralf-Uwe Kuehnel, MD,
Johannes M. Albes, MD, PhD
Department of Cardiovascular Surgery, Heart Center Brandenburg, Bernau, Berlin, Germany
Accepted for publication May 19, 2005.
* Address correspondence to Dr Hartrumpf, Department of Cardiovascular Surgery, Heart Center Brandenburg, Ladeburger Strasse 17, Bernau bei Berlin, 16321 Germany (Email: m.hartrumpf{at}immanuel.de).
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Abstract
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The first case of a fracture of a semi-rigid annuloplasty device is reported. A 56-year-old man presented with recurrence of severe mitral and tricuspid regurgitation 10 months after proper implantation of a Colvin-Galloway Future band (Medtronic Inc, Minneapolis, MN). During redo surgery we made the unexpected finding that its metal skeleton was fractured near the posterior segment. A tear in the anterior mitral leaflet was also found. It is speculated that the device fracture may have put additional strain on the native annulus.
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Introduction
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Fractures of modern annuloplasty devices are rare events. They have only been described in the tricuspid position in the early 1980s [1–3]. This is the first case report about such an incident in one of the latest mitral annuloplasty systems. We herein report the fracture of a Colvin-Galloway Future band device (Medtronic Inc, Minneapolis, MN) as an unexpected finding during a redo operation for mitral regurgitation.
A 56-year-old male patient was referred to our institution from an external hospital where he had presented with clinical signs of congestive heart failure. He complained of reduced fitness, ankle edema, and dyspnea. The chest roentgenogram showed signs of pulmonary congestion. Ten months prior, he had undergone aortic valve reconstruction and ascending aortic and proximal arch replacement for an aortic aneurysm as well as a mitral valve repair for severe mitral regurgitation at our institution. A 36-mm Colvin-Galloway Future band (Medtronic Inc) had been implanted according to published standard techniques [4]. Eleven U-shaped, non-pledgetted, interrupted sutures had been placed symmetrically along the circumference in an equidistant fashion with the commissures attached first. The immediate postoperative result had been excellent showing no residual regurgitation.
Current echocardiography at the time of readmission showed recurrence of significant mitral regurgitation (grade III) with concomitant severe pulmonary hypertension and newly developed tricuspid regurgitation (grade III). Transesophageal echocardiography confirmed these findings and uncovered a mitral regurgitation jet directed to the left atrial roof. Laboratory results revealed signs of hemolysis. After recompensation the patient was urgently referred to our institution to undergo mitral and tricuspid valve repairs. After redo sternotomy, total cardiopulmonary bypass was established at a temperature of 28°C. Inspection of the mitral valve showed a 1-cm tear in the base of the A3 segment of the anterior leaflet. The Colvin-Galloway Future band (Medtronic Inc) was firmly anchored in the native tissue but showed instability close to this region. After excision of the device, we made the unexpected discovery of a fracture in the metal skeleton near the posteromedial commissure causing deviation from the regular shape. Further inspection revealed a perforation of the enwrapping tissue by the broken wire (Fig 1). Due to the lesion in the anterior leaflet, a valve repair was not feasible. Therefore we excised the AML and replaced the valve with a 31-mm bi-leaflet prosthesis. During rewarming, a DeVega plasty was performed. Weaning from cardiopulmonary bypass was uneventful. The patient recovered quickly and could be released from the intensive care unit after 2 days. Postoperative echocardiography showed proper function of the mitral valve prosthesis (dPmean, 5 mm Hg) and insignificant tricuspid regurgitation. Ejection fraction was measured 65% to 70%. Due to total atrioventricular block, temporary pacing was maintained and eventually replaced by a sequential pacemaker on day 8. The patient was prescribed coumarin and was discharged from hospital on day 16.
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Fig 1. Detail of the fractured Colvin-Galloway Future band (Medtronic Inc, Minneapolis, MN). In the region of the posteromedial commissure, the device shows a deviation from the regular shape due to its loss of stability. The steel wire has perforated the enwrapping tissue at the fractured site.
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Comment
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Mitral valve repair techniques have evolved during the decades. One of the landmarks is the use of annuloplasty devices, such as the rigid annuloplasty ring by Carpentier [5] or the semi-rigid annuloplasty band by Cosgrove [6]. The intention of such devices is to maintain the anatomical shape of the mitral annulus with its characteristic 4 to 3 ratio between the transversal and the anteroposterior diameter. Proper apposition of the anterior and posterior leaflet is thereby regained. The advantage of semi-rigid devices lies in their flexibility preserving the physiologic motion of the annulus, which in turn reduces transvalvular gradient [7]. A relatively new device in this category is the Colvin-Galloway Future band (Medtronic Inc). Its metal skeleton consists of MP-35N alloy (SPS Technologies Inc, Jenkintown, PA), which represents a nonmagnetic, nickel-cobalt-chromium-molybdenum alloy to allow for stiffness and flexibility at the same time. The first clinical results have been promising [4].
At the time of explantation, we found that the device was still properly attached to the mitral annulus. Neither was any of the eleven sutures ruptured or torn out of the native tissue, nor was the sewing ring ripped up. An isolated fracture of the steel wire was encountered instead, which came into full vision after explantation of the device. Based on the assumption that the tensile strength of the metal skeleton exceeded that of the surrounding soft tissues, one might expect that the device would resist the external forces rather than the native annulus. Technical errors such as placement of wide sutures across the commissures, which may promote strain on the device, could be ruled out. The sutures had been placed in a standard fashion along the device's circumference without excessive tension [4]. Moreover, comparison of roentgenograms after early discharge and at readmission showed that the fracture must have occurred during this interval (Fig 2). Because pulmonary hypertension and tricuspid insufficiency may have developed secondary to the mitral lesion, the incident is likely to have occurred relatively early after implantation.
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Fig 2. Details of the corresponding lateral-view chest roentgenograms prior to discharge (left view, no device fracture) and prior to reoperation (right view, with device fracture). The arrow indicates the resulting deformity.
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Therefore we speculate that the isolated fracture of the steel wire may be an expression of a single instance of material fatigue. It is due to their nature that flexible annuloplasty systems are more exposed to deformation and strain than rigid devices. The resulting pseudo joint at the posteromedial commissure may have in part contributed to the subsequent tear in the anterior leaflet. Therefore we would suggest considering such a device failure as a rare cause of mitral valve insufficiency after annuloplasty. However it remains unclear whether our case may be indicative of an inherent error in flexible annuloplasty systems.
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References
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- Galinanes M, Duarte J, de Caleya DF, Garcia-Dorado D, Fdez-Aviles F, Elbal LM. Fracture of the Carpentier-Edwards ring in tricuspid positiona report of three cases. Ann Thorac Surg 1986;42(1):74-76.[Abstract]
- de Caleya D, Sarnago F, Galinanes M, Duarte J. Fracture of Carpentier's ring in a patient with tricuspid annuloplasty Thorac Cardiovasc Surg 1983;31(3):175-176.[Medline]
- Kay HR, Hammond GL. Fracture of a prosthetic tricuspid annular ring J Thorac Cardiovasc Surg 1982;83(4):635.[Medline]
- Fasol R, Meinhart J, Deutsch M, Binder T. Mitral valve repair with the Colvin-Galloway Future band Ann Thorac Surg 2004;77(6):1985-1988.[Abstract/Free Full Text]
- Carpentier A, Deloche A, Dauptain J. A new reconstructive operation for correction of mitral and tricuspid insufficiency J Thorac Cardiovasc Surg 1971;61(1):1-13.[Medline]
- Cosgrove III DM, Arcidi JM, Rodriguez L, Stewart WJ, Powell K, Thomas JD. Initial experience with the Cosgrove-Edwards Annuloplasty system Ann Thorac Surg 1995;60(3):499-503.[Abstract/Free Full Text]
- Sharony R, Saunders PC, Nayar A, et al. Semirigid partial annuloplasty band allows dynamic mitral annular motion and minimizes valvular gradientsan echocardiographic study. Ann Thorac Surg 2004;77(2):518-522.[Abstract/Free Full Text]
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Abstract
Introduction
