eComment: Early stentless aortic prosthesis dysfunction due to interlayer hematoma formation

Interactive CardioVascular and Thoracic Surgery, Sep 2011

Leo A. Bockeria, Ruslan A. Lazarev, Ravil M. Muratov

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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. - 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)


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Leo A. Bockeria, Ruslan A. Lazarev, Ravil M. Muratov. eComment: Early stentless aortic prosthesis dysfunction due to interlayer hematoma formation, Interactive CardioVascular and Thoracic Surgery, 2011, pp. 349-350, 13/3, DOI: 10.1510/icvts.2011.272773A