Technical Details of Redo Aortic Valve Replacement using St. Jude Medical Mechanical Prosthesis in a Patient with Thrombosed Aortic Mechanical Prosthesis: A Video Presentation

Current consensus guidelines of the AHA and ESC, uniformly recommend either type of prosthetic valve for patients aged 60 to 70 years and mechanical prosthesis for patients aged less than 60 years

365 Combining mechanisms of prosthetic valve dysfunction

A 32-year-old female was referred to our outpatient clinic for exertional dyspnoea that had worsened in the preceding months. She had a history of mitral and aortic valve replacement with bileaflet mechanical prosthesis (St. Jude Master n. 25 and Medtronic Open Pivot n. 16, respectively) for rheumatic heart disease. A recent echocardiography showed borderline-high trans-aortic gradients (mean 26 mmHg, peak 42 mmHg). Transthoracic echocardiography revealed abnormal aortic transprosthetic flow (peak velocity 442 cm/s, mean gradient 48 mmHg). Continuous Wave Doppler signal was rounded with a long acceleration time (108 ms). Effective orifice area (EOA) was 0.8 cmq (index EOA 0.48 cmq/mq) and Doppler Velocity Index 0.28. Further investigations revealed no signs of infections but suboptimal anticoagulation (INR 2.5). Transesophageal 3D echocardiography was suggestive for hypomobility of the prosthetic leaflets and the presence of an isoechoic mass encircling the ventricular side of the aortic prosthesis compatible with pannus overgrowth. Cardiac CT confirmed the presence of a symmetrical reduction in the systolic opening of both leaflets. The patient underwent a redo of aortic valve replacement that confirmed the presence of an asymmetric subprosthetic pannus overgrowing on the previously implanted surgical pledgets. After pannus debritment a St. Jude Regent n. 21 was implanted. The patient experienced complete symptomatic resolution. We presented the case of a prosthetic aortic valve dysfunction due to a combination of patient-prosthesis mismatch and pannus overgrowth. In our patient, as assessed in the old echocardiographic examinations, the presence of mildly elevated transprosthetic gradients was suggestive for prosthesis undersizing related to body surface area. In this scenario, subvalvular pannus formation caused significant changes in prosthetic valve transvalvular flow dynamic leading to prosthesis dysfunction. This case emphasises the crucial role of echocardiographic follow up in detection of causes of prosthetic heart valve dysfunction and how optimal valve sizing is paramount in aortic valve replacement.

Surgical Aortic Valve Replacement—Age-Dependent Choice of Prosthesis Type

Background: Recently, the use of surgically implanted aortic bioprostheses has been favoured in younger patients. We aimed to analyse the long-term survival and postoperative MACCE (Major Adverse Cardiovascular and Cerebral Event) rates in patients after isolated aortic valve replacement. Methods: We conducted a single-centre observational retrospective study, including all consecutive patients with isolated aortic valve replacement. 1:1 propensity score matching of the preoperative baseline characteristics was performed. Results: A total of 2172 patients were enrolled in the study. After propensity score matching the study included 428 patients: 214 biological vs. 214 mechanical prostheses, divided into two subgroups: group A < 60 years and group B > 60 years. The mean follow-up time was 7.6 ± 3.9 years. Estimated survival was 97 ± 1.9% and 89 ± 3.4% at 10 years for biological and mechanical prosthesis, respectively in group A (p = 0.06). In group B the survival at 10 years was 79.1 ± 5.8% and 69.8 ± 4.4% for biological and mechanical prosthesis, respectively (p = 0.83). In group A, patients with a bioprosthesis exhibited a tendency for higher cumulative incidence MACCE rates compared to patients with a mechanical prosthesis, p = 0.83 (bio 7.3 ± 5.3% vs. mech 4.6 ± 2.2% at 10 years). In group B, patients with a mechanical prosthesis showed a tendency for higher cumulative incidence MACCE rates compared to patients with bioprosthesis, p = 0.86 (bio 4.3 ± 3.1% vs. mech 9.1 ± 3.1% at 10 years). Conclusions: Long-term survival after surgical aortic valve replacement is similar in patients with a biological and mechanical prosthesis, independent of the patients’ age. Moreover, younger patients (<60 years) with bioprosthesis showed a survival benefit, compared to patients with mechanical prosthesis in this age group.

Redo Mitral Valve Replacement using St. Jude Medical Mechanical Prostheses in a Patient with Degenerated Mitral Perimount Bioprosthesis: A Video Presentation

Current consensus guidelines of the American Heart Association and European Society of Cardiology, uniformly recommend either type of prosthetic mitral valve for patients aged 60 to 70 years, and mechanical prosthesis for patients less than 60 years.

DESIGN AND DEVELOPMENT OF IMPURITIES FREE PYROLYTIC COATED MECHANICAL BI-LEAFLET HEART VALVE PROTOTYPE

Heart valve problems affect more than 100 million people worldwide. According to statistics, around 55% of valvular diseases are treated by a mechanical prosthesis. The first heart valve replaced model was the caged-ball valve, more than 50 models of heart valves designed by different companies. Each design has different aspects such as valve geometry, leaflets design, materials used for model manufacturing, coating techniques, and coating materials. Depending on the patient's need and condition, the native heart valve either replaced by a biological or mechanical heart valve. Biological valves are made of living tissues whereas mechanical valves manufactured by the biomaterials, which are biocompatible and do not causes any reaction inside the body. The prototype discussed in this paper provides good hemocompatibility, because of the biomaterial used in this prototype manufacturing. It will reduce tissue ingrowth, due to the enhanced leaflet ear of the orifice ring. Moreover, it will cause less thrombotic effects into the host due to greater contact angel of graphite and smooth surface of graphite after pyrolytic coating. The significant evolution of mechanical valve designs consists of valve geometry, coating technique, and materials. In this research, the 3D-CAD model of Bileaflet Mechanical Mitral Heart Valve was designed using SOLID WORKS 2016 and fabricated by 5-axis Computer Numeric Control (CNC) machine. Graphite was used for the fabrication of prototype and Pyrolytic Carbon (PyC) coating was performed with Chemical Vapor deposition (CVD) technique. Scanning electron microscopy (SEM), Fourier Transform Infrared Spectroscopy (FTIR), and X-ray Diffraction (XRD) were used to determine the effects of CVD on surface topography and chemical structure of graphite model before and after coating. Furthermore, hemocompatibility of graphite and PyC analyzed through in-vitro hemolytic activity. The Characterization results showed that the Bileaflet Mechanical Mitral Heart valve prototype after PyC coating provides a smooth surface with improved hemocompatibility and less adhesion. Besides, the Mechanical Heart valves showed no hemolysis during the hemolytic activity. By virtue of its smooth and nonporous surface, it is antithrombotic and provides good hemodynamics. The advance long leaflet ear design reduces the tissue ingrowth around the orifice which will further limit the leaflets movement.

Third Re-Do Surgery in a Young Woman with Massive Early Double-Valve Prosthesis and Thromboembolic Stroke

Valvular heart disease affects more that 100 million people worldwide. Valvular replacement remains the only definite treatment for most of the patients with severe disease. Careful medical management and periodic followup of valve function is mandatory in order to prevent or diagnose prosthesis-related complications. We present a case of extensive mitral and aortic valve thrombosis and possible recurrent endocarditis in a 44-year-old woman non-adherent to anticoagulation therapy, presented with stroke. She also had a history of two mitral and aortic valvular heart replacement surgeries. Comprehensive and repeated imaging was used to evaluate and monitor the patient progression and outcome. Failure of adequate anticoagulation therapy to improve prosthesis function during hospitalization required third re-do surgery for mitral and aortic valve replacement with mechanical prosthesis.

Redo Aortic and Mitral Valve Replacement using St. Jude Medical Mechanical Prosthesis in a Patient with Degenerated Mitral Bioprosthesis and Severe Aortic Regurgitation: A Video Presentation

The American College of Cardiology/American Heart Association practice guidelines suggest bioprosthetic aortic and mitral valve replacement is a reasonable option for patients older than 65 years and for selected patients younger than 65 years according to patients’ preference. However, routine use of bioprosthetic valves in younger patients remains controversial. Patients prevalence to avoid anticoagulation, decreasing operative risks for valve reoperations, and the availability of catheter valve-in-valve techniques have created a need to reexamine bioprosthetic valve durability, particularly in young patients undergoing valve replacements

Surgical Repair of Unruptured Pseudoaneurysm of Sinus of Valsalva in Aortic Stenosis

Isolated pseudoaneurysm of a sinus of Valsalva is an uncommon sequelae of infective endocarditis. It is very uncommon in native aortic valve stenosis as compared to aortic regurgitation. We present a case of a 46 year old gentleman with a severely stenotic aortic valve with infective endocarditis, and a pseudoaneurysm of the non coronary sinus of Valsalva. The pseudoaneurysm was repaired with a prosthetic patch and the aortic valve was replaced by a mechanical prosthesis. Transthoracic echocardiography and computed tomography aortogram are an ideal diagnostic tools in suspected cases. Surgery can be curative with excellent results.