eComment: Early stentless aortic prosthesis dysfunction due to interlayer hematoma formation
P. Donndorf et al. / Interactive CardioVascular and Thoracic Surgery 13 (2011) 348-350 [1] David TE. Aortic valve replacement with stentless porcine bioprostheses. J Card Surg 1998;13:344-351. [2] Gulbins H, Reichenspurner H. Which patients benefit from stentless aortic valve replacement? Ann Thorac Surg 2009;88:2061-2068. [3] Kallikourdis A, Jacob S. Is a stentless aortic valve superior to conventional bioprosthetic valves for aortic valve replacement? Interact CardioVasc Thorac Surg 2007;6:665-672. [4] Kunadian B, Vijayalakshmi K, Thornley AR, de Belder MA, Hunter S, Kendall S, Graham R, Stewart M, Thambyrajah J, Dunning J. Metaanalysis of valve hemodynamics and left ventricular mass regression for stentless versus stented aortic valves. Ann Thorac Surg 2007;84: 73-78. [5] Giordano V, Hermens JA, Wajon EM, Grandjean JG. Rare prosthesis failure after aortic valve replacement with a Freedom Solo. Interact CardioVasc Thorac Surg 2011;12:273-275.
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Fig. 1. Intraoperative images of the explanted RootElan prosthesis. The white
arrows indicate the stenotic swelling located at the bottom of the right
coronary cusp and partially involving the non-coronary cusp.
Before implantation, patch enlargement of the proximal
aorta was necessary due to a narrow sinotubular junction.
The prosthesis was then implanted routinely using
interrupted mattress sutures. After closing the aorta,
intraoperative TEE showed adequate function of the prosthesis.
The subsequent postoperative course was uneventful,
and the patient was discharged from hospital in a stable
cardiopulmonary condition. Examination of the explanted
prosthesis by the manufacturer did not reveal any evidence
for a primary quality defect as a reason for the stenotic
swelling.
3. Discussion
Implantation of stentless aortic valve prostheses offers
potential benefits in terms of hemodynamics and patient
survival, although meta-analyses performed so far have not
been conclusive when analyzing the long-term clinical
differences between patients treated with either stented or
stentless aortic valves [3]. The implantation itself is
technically more demanding than the implantation of a stented
valve, with the need to sew not only the annulus, but also
the commissures and the distal end of the prosthesis to
the aortic wall, thereby avoiding any geometric distortion.
The times on cardiopulmonary bypass and aortic
crossclamping are consequently elongated [4]. However, to our
knowledge, an early stenotic failure due to postoperative
swelling of a stentless aortic valve prosthesis has not yet
been described.
As exploration of the explanted prosthesis by the
manufacturer did not show any primary quality defect of the
prosthesis, the reason for the early stenotic failure, after
adequate initial function, as documented by intraoperative
TEE, remains unclear. It is conceivable that the swelling was
caused by fluid or blood accumulating under the layer of
porcine pericardium reinforcing the annulus in the wall of
the prosthesis. Although not conclusively proven in the
histological work-up of the explant, this has to be considered
as a possible drawback of the RootElan prosthesis and its
double-layered construction.
Early degeneration and technical malfunctioning of an
intact biological prosthesis might also be explained by an
unexpected and unknown primary tissue failure [5]. On
the other hand, technical problems caused by suture lines
cannot be ruled out completely, although intraoperative
inspection did not reveal any impairment of the prosthesis
caused by the suture lines. Finally, a possible idiosyncratic
response to the device has to be considered.
4. Conclusions
In conclusion, our case underlines the importance of early
and routine postoperative echocardiography in patients
after aortic valve surgery, especially after implantation
of the technically more demanding and more
vulnerable stentless valves. In order to avoid technical
problems, that is, buckling of the ring caused by suture lines,
it might be feasible to rotate the RootElan prosthesis with
respect to the morphology of the native annulus prior to
implantation.
eComment: Early stentless aortic prosthesis dysfunction due to
interlayer hematoma formation
The problem of biological prosthesis in young patients is well-known and is
widely covered in numerous scientific publications. This drawback of
bioprostheses, restricted their usage in patients younger than 65 years. These failures
are caused by calcification and structural deterioration in the midterm period.
In this context, the described case is of particular interest. In our opinion
this early postoperative prosthesis failure is caused by liquid accumulation
between prosthesis layers. At our center we have significant experience of
stentless valve implantation. Initially we started to use home-made
xenografts reinforced with xenopericardium. In spite of full root replacement
technique application we faced such complications as hematoma
formation between pro (...truncated)