Ann Thorac Surg 2007;83:2210-2213
© 2007 The Society of Thoracic Surgeons
Case Reports
Late Disruption of a Freestyle Stentless Bioprosthesis Used for Repair of Sinus of Valsalva Aneurysm of Noncoronary Cusp
Yoshiyuki Takami, MDa,*,
Hiroshi Masumoto, MDb,
Biliie Fyfe-Kirschner, MDc
a Department of Cardiovascular Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan
b Division of Cardiovascular Surgery, Kasugai Municipal Hospital, Kasugai, Japan
c Department of Pathology, UMDNJ-Robert Wood Johnson Medical School, New Brunswick, New Jersey
Accepted for publication January 8, 2007.
* Address correspondence to Dr Takami, Department of Cardiovascular Surgery, Nagoya Daini Red Cross Hospital, 2-9 Myouken-cho, Showa-ku, Nagoya, 466-8650, Japan (Email: takami{at}nagoya2.jrc.or.jp).
 |
Abstract
|
|---|
We present a case of disruption of the porcine aortic wall of the 27-mm Freestyle stentless bioprosthesis 5 years after the subcoronary implantation to exclude the sinus of Valsalva aneurysm of the noncoronary cusp. At the urgent reoperation, the inflow suture line was found to be intact, and therefore a new stented valve was sutured with the inflow Dacron cuff after removal of ruptured valve. The subcoronary implantation technique creates a cavity between the prosthetic and native aortic walls filled with hematoma. The outflow suture line dehiscence caused blood flow into the cavity, porcine aortic wall rupture, and leaflet destruction.
|
Introduction
|
|---|
The Freestyle stentless bioprosthesis (Medtronic Inc, Minneapolis, MN) has been more frequently applied for aortic valve or root disease based on its potential hemodynamic advantages over stented valves [1–4]. There have been a few reports describing dehiscence or disruption of the Freestyle valve [5, 6]. We report an uncommon case of ruptured porcine aortic wall of the Freestyle stentless bioprosthesis 5 years after the subcoronary implantation to exclude the sinus of Valsalva aneurysm of the noncoronary cusp.
A 72-year-old woman had dyspnea and general edema. Echocardiography indicated severe aortic regurgitation and aneurysmal dilatation of the noncoronary sinus of Valsalva. The sinotubular junction did not appear dilated (24 mm) in the magnetic resonance examination. Surgical treatment was selected for the patient, and a 27-mm Freestyle stentless aortic root bioprosthesis was implanted with a modified subcoronary technique under moderate hypothermic cardiopulmonary bypass on March 13, 2000 [7]. The inflow anastomosis was accomplished with 28 simple interrupted 3-0 polyester sutures. The outflow suture was accomplished with a continuous running suture of 4-0 polypropylene, starting at the bottom of the left and right coronary sinuses. As also described by Campo and Weinberg [8], we covered and excluded the aneurysmal noncoronary sinus of Valsalva with the bioprosthesis wall (Fig 1). The patient was discharged without any complications 34 days after surgery. Echocardiographic findings immediately after surgery demonstrated massive hematoma between the prosthetic wall and the native noncoronary sinus of Valsalva. As we reported previously [7], however, the perivalvular hematoma around the Freestyle valve resolved, with a resultant small space, 4 years after implantation (Fig 2).
View larger version (14K):
[in this window]
[in a new window]
|
Fig 1. (Left) Schema of the first operation of aortic valve replacement with a 27-mm Freestyle stentless aortic root bioprosthesis. (Right) Schema of speculated mechanism of disruption of the implanted Freestyle bioprosthesis. At first, the outflow suture line on the porcine aortic wall of the Freestyle valve was disrupted (left arrow, down). Thereafter, the tear of the aortic wall was extended into the valve leaflet, causing valve regurgitation (right arrow, up).
|
|
View larger version (90K):
[in this window]
[in a new window]
|
Fig 2. (Upper panel) Transthoracic echocardiogram approximately 2.5 years after the first surgery, showing the absorbed space with the perivalvular hematoma between the prosthetic wall and native noncoronary sinus. (Lower panel) Transthoracic echocardiogram just before the reoperation for the disrupted Freestyle valve, showing the enlarged space between the prosthetic wall and native noncoronary sinus, with blood flow into the cavity.
|
|
The patient’s conditions had been uneventful until abnormal diastolic murmur was found approximately 5 years after surgery. Echocardiography revealed aortic regurgitation and blood flow into the cavity between the bioprosthesis wall and the sinus of Valsalva (Fig 2). The patient presented with progressive edema and dyspnea, associated with increased volume of regurgitation. Freestyle valve dysfunction was diagnosed, and urgent reoperation was performed under cardiopulmonary bypass instituted with aortic and bicaval cannulations on July 26, 2005. When the ascending aorta was reopened, we found that the porcine aortic wall of the Freestyle valve was disrupted with the tear extended into the valve leaflet, causing valve regurgitation (Fig 1). We found a large amount of old hematoma in the space between the porcine wall and the native noncoronary sinus of Valsalva. After the hematoma was removed and the valve leaflets were resected, we found that the inflow suture line was intact, and therefore we sutured a 23-mm Carpentier Edwards Perimount Pericardial Bioprosthesis (Edwards Lifesciences, Irvine, California) with the inflow Dacron cuff, except for which all the disrupted valve components were removed. The patient was weaned easily from cardiopulmonary bypass, and her postoperative course was uneventful. The patient was discharged without any severe complications. Pathology examination of the resected Freestyle valve revealed that the portion of the porcine aortic wall demonstrated marked degeneration, with degeneration of elastic lamellae. It also revealed fibrosis of the porcine valve cusp (Fig 3). Cultures and Gram stain appeared negative for organisms.
View larger version (148K):
[in this window]
[in a new window]
|
Fig 3. Gross photograph of largest fragment of resected aortic wall (A) demonstrating wrinkling, wearing, and thinning of the edges. Inset photomicrograph of aortic wall with marked degeneration of elastic lamellae (arrowhead) adjacent to exterior hematoma. (Inset: pentachrome stain, x100.)
|
|
|
Comment
|
|---|
Among the techniques of implanting the Freestyle bioprosthesis [1, 9, 10], the modified subcoronary technique is frequently used because of its ease [4]. A major concern when the subcoronary technique is used is hematoma in the potential space between the prosthetic and native aortic walls. This double suture line implantation with preserved noncoronary sinus creates a cavity wall, which is particularly large in the noncoronary sinus. Intraoperatively, this cavity is probably filled with blood before heparin is antagonized. Increased pressure may ensue if blood continues to pass across the suture line and inflates the cavity. This increased pressure may cause excessive suture traction, particularly in the noncoronary sinus where the two walls can separate widely. Following the above pathophysiology, most of the early dehiscencies were reported to be located beneath the noncoronary sinus, leading to dehiscence of the outflow suture line and periprosthetic leak. In the summarized report by Schoof and colleagues [5], the mean interval between the original valve replacement and reoperation for prosthetic dehiscence was 18 months (range, 2.5 to 49). In our patient, however, the reoperation was performed 5 years after the original valve replacement.
We have already reported evident absorption of the hematoma in the cavity wall in the same patient [7]. We have confirmed the morphologic resolution over time of the perivalvular hematoma with echocardiographic follow-up as long as 4 year after the original surgery. As revealed in the reoperation, the cavity of the noncoronary sinus was filled with old hematoma. Nevertheless, the outflow suture line was disrupted, and the blood flow might have resumed into the cavity space. We think that the reason for disruption of the outflow suture is fragility of the porcine aortic wall in the long-term point of view. Our pathology examination revealed marked degeneration with distorted elastic lamellae of the porcine aortic wall. This may be an important finding that has never been pointed out. We need to pay attention to the long-term durability of the porcine aortic wall of the Freestyle valve.
Although good results were reported with the continuous suture technique, Schoof and associates [5] advocated multiple interrupted nonabsorbable sutures for the outflow suture and a few mattress sutures to close the cavity wall in the noncoronary sinus. Based upon the findings of the present case, we should not use the modified subcoronary technique to implant the Freestyle valve in such a patient. When we use the Freestyle valve, we should apply the full-root technique. Alternatively, we should perform an aortic valve replacement using a stented bioprosthetic valve and an ascending aortic replacement using a Dacron graft with a tongue-shaped part to replace the noncoronary sinus.
The incidence of dehiscence or early reoperation has been reported to be 5% to 6% for subcoronary implantation [5]. Although the late incidence may be lower, we should recognize the potential space between the prosthetic and native aortic walls in the subcoronary implantation of the Freestyle bioprosthesis as a possible predisposing factor to late prosthetic dehiscence.
|
References
|
|---|
- Kon ND, Westaby S, Amarasena N, Pillai R, Cordell AR. Comparison of implantation techniques using the Freestyle stentless porcine aortic valve Ann Thorac Surg 1995;59:857-862.[Abstract/Free Full Text]
- Jin XY, Westaby S, Gibson DG, Pillai R, Taggart DP. Left ventricular remodeling and improvement in Freestyle stentless valve hemodynamics Eur J Cardiovasc Surg 1997;12:63-69.
- Cartier PC, Dumesnil JG, Metras J, Desaulniers D, Doyle DP, Lemieux, MD. Clinical and hemodynamic performance of the Freestyle aortic root bioprosthesis Ann Thorac Surg 1999;67:345-351.[Abstract/Free Full Text]
- Ohtake S, Sawa Y, Sakaguchi T, et al. Early experience of aortic valve replacement with the Freestyle stentless aortic bioprosthesis in elderly patients Jpn J Thorac Cardiovasc Surg 2000;48:222-228.[Medline]
- Schoof PH, Baur LH, Kappetein AP, Hazekamp MG, van Rijk-Zwikker GL, Huysmans HA. Dehiscence of the Freestyle stentless bioprosthesis Semin Thorac Cardiovasc Surg 1999;11(Suppl 1):133-138.[Medline]
- Kameda Y, Mizuguchi K, Kawata T, Mori T, Taniguchi S. Aortopulmonary fistula due to perforation of the aortic wall of a Freestyle stentless valve Ann Thorac Surg 2004;78:1827-1829.[Abstract/Free Full Text]
- Takami Y, Ina H. Resolution of perivalvular hematoma of the Freestyle stentless aortic root bioprosthesis implanted with a subcoronary technique Jpn J Thorac Cardiovasc Surg 2001;49:675-678.[Medline]
- Campo CD, Weinberg DM. Sinus of Valsalva aneurysm of the non-coronary cusp, repaired in the adult with a Freestyle bioprosthesis Tex Heart Inst J 2003;30:202-204.[Medline]
- O’Brien MF, McGiffin DC, Stafford EG. Allograft aortic valve implantation: techniques for all types of aortic valve and root pathology Ann Thorac Surg 1989;48:600-609.[Abstract]
- Kon ND, Cordell AR, Adair SM, Dobbins JE, Kitzman DW. Aortic root replacement with the Freestyle stentless porcine aortic root bioprosthesis Ann Thorac Surg 1999;67:1609-1616.[Abstract/Free Full Text]
This article has been cited by other articles:
|
|
|
|
 
T. E. David, S. Armstrong, M. Maganti, J. Butany, C. M. Feindel, and J. Bos
Postimplantation morphologic changes of glutaraldehyde-fixed porcine aortic roots and risk of aneurysm and rupture.
J. Thorac. Cardiovasc. Surg.,
January 1, 2009;
137(1):
94 - 100.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
T. Mizuno
Wall rupture of Medtronic Freestyle stentless porcine aortic root bioprosthesis
Interactive CardioVascular and Thoracic Surgery,
December 1, 2008;
7(6):
1129 - 1130.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
T. Albacker, A. Al Kindi, and B. de Varennes
Traumatic Dehiscence of Medtronic Freestyle Stentless Bioprosthesis
Ann. Thorac. Surg.,
August 1, 2008;
86(2):
643 - 645.
[Abstract]
[Full Text]
[PDF]
|
|
|
Top
Abstract
Introduction
