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Video Presentation | DOI: https://doi.org/10.31579/2641-0419/223
1Cardiothoracic Sciences Centre, All India Institute of Medical Sciences, New Delhi
2Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, Bilaspur, Himachal Pradesh.
*Corresponding Author: Ujjwal Kumar Chowdhury, Professor Department of Cardiothoracic and Vascular Surgery AIIMS, New Delhi 110029, INDIA
Citation: Ujjwal Kumar Chowdhury, Niwin George, Lakshmi Kumari Sankhyan, Gaind Saurabh, Shweta Sharma, Shikha Goja M, Niraj Nirmal Pandey. (2021) Redo Mitral Valve Replacement using St. Jude Medical Mechanical Prostheses in a Patient with Degenerated Mitral PERIMOUNT Bioprosthesis: A Video Presentation. J. Clinical Cardiology and Cardiovascular Interventions, 4(17); Doi:10.31579/2641-0419/223
Copyright: © 2021 Ujjwal Kumar Chowdhury, This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Received: 10 September 2021 | Accepted: 12 October 2021 | Published: 18 October 2021
Keywords: heart disease; pulmonary artery; cardiopulmonary bypass
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.
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. [1-4]
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 re-examine bioprosthetic valve durability, particularly in young patients undergoing valve replacements. [5-8]
Younger patients with rheumatic heart disease undergoing mechanical mitral valve replacement require life-long anticoagulation and are at risk of bleeding and thromboembolic complications. [5-15]
The reported incidence of survival following mechanical mitral valve replacement in the published literature at 10, 20, and 30 years is 61-75%, 36.5-39% and 22.6% respectively. [5-15] Although tissue heart valves are an established choice in older age groups, there is a reluctance in using tissue valves in younger age groups because of higher reoperation rates which are inversely proportional to the age of the patients. [5-15]
Over the last 20 years, there is a shift away from a clear cut age limit towards patients’ wish and lifestyle considerations. [2,16,17]
The Carpentier-Edwards Perimount pericardial bioprosthetic (Edwards Lifesciences, Irvine, CA) is a second generation trileaflet bioprosthetic valve consisting of bovine pericardial leaflets mounted on a flexible frame. The design of the valve was aimed at improving on the limited durability of porcine bioprosthesesand poor performance of the first-generation pericardial valves. [6,7,18-21]
Studies on long-term new generation Carpentier-Edwards pericardial bioprosthesis (Perimount) have documented excellent hemodynamic profile and a low incidence of structural deterioration with freedom from reoperation being 89.5%±5% at 15 years. [6,7,18-21]
With this background, a group of 295 patients aged less than 40 years underwent mitral valve replacement using St. Jude Medical Epic, and Carpentier Edwards PERIMOUNT bioprosthesis by the corresponding author at All India Institute of Medical Sciences, New Delhi, India, between January 2000 and December 2019. [22]
Among them, 165 patients underwent Carpentier Edwards PERIMOUNT bioprosthetic implantation. The actuarial survival at a median follow-up of 134 (IQR: 99.5-178.50) months was 96.36%±0.01% (95% CI: 93.11-98.10). Thirty patients developed severe bioprosthetic degeneration with predominant stenosis between 7 and 10 years after primary tissue valve replacement. [22]
We report herein one of our patients from this series who underwent mitral valve replacement 11 years back using a 29 mm Carpentier-Edwards pericardial perimount prosthesis. He underwent mitral valve replacement using St. Jude Medical Mechanical Prosthesis. The indication for reoperation was severe bioprosthetic degeneration. He was weaned off cardiopulmonary bypass on dopamine 5µg/kg/min and dobutamine 10µg/kg/min and adrenaline 0.01 µg/kg/min with stable hemodynamics. At 48 months follow-up, the patient has been doing well in NYHA class-II with normal mitral prosthetic valve function, and minimal medications.
Following systemic heparinisation, elective right femoral arteriovenous cannulation is done using long femoral arterial and venous cannulae (Edwards Lifesciences LLC, One Edwards Way, Irvine, CA, USA).
Under cardiopulmonary bypass, secondary median sternotomy was performed with the heart decompressed on bypass. The Dacron synthetic patch overlying the aorta, right ventricular outflow tract and superior vena cava was dissected.
The superior caval vein was dissected and cannulated directly using an angled metal tipped venous cannula and drained directly into the oxygenator. An 18-Fr sump suction vent was placed over the main pulmonary artery for further decompression of the heart to facilitate dissection. The intrapericardial inferior caval vein was dissected and looped for later occlusion.
The right pleural cavity was widely opened. Due to dense adhesions overlying the right and left atrium, the pericardium overlying body of the right atrium was not dissected. The patient was planned for transeptal approach of mitral re-replacement.
The aorta was cross-clamped using an atraumatic aortic vascular clamp. Myocardial preservation was achieved by integrated myocardial protection using direct osteal St. Thomas (II) based cold blood cardioplegia (4:1) and topical cardiac cooling using ice cold saline.
Successive doses of cardioplegia were repeated every 30 minutes.
After snugging the inferior caval vein, the pericardium overlying the right atrium was directly incised in between stay sutures. The interatrial septum was incised and opened in between stay sutures.
Two stay sutures of 2-0 Ethibond (Johnson and Johnson Ltd., Ethicon, LLC, San Lorenzo, USA) were placed over the prosthetic mitral annulus to facilitate later explantation of the mitral prosthesis.
An incision was made on the mitral prosthetic ring using a No.11 scalpel blade. The prosthetic valve was detached from the anterior atrioventricular groove by a combined sharp and blunt dissection.
A small right angle forceps was insinuated within the opening to facilitate explantation of the mitral prosthesis. The prosthetic valve was explanted by incising the prosthetic fibrous capsule on both atrial and ventricular surface. Extreme precautions were taken not to cause type I atrioventricular groove rupture. Precautions were also taken not the dislodge the thrombus contained within the prosthetic mitral valve. The posterior chordal apparatus was retained. The ventricular cavity is irrigated using cold normal saline.
Re-replacement of the mitral valve is done using a 29 mm St. Jude Mechanical prosthesis (St. Jude Medical; St Jude Medical; St. Paul, MN, USA) and interrupted 2-0 Ticron mattress suture.
The surgically created atrial septal defect was reconstructed using a Dacron polyester patch (Bard® Savage® filamentous knitted polyester fabric, Bard Peripheral Vascular Inc., Tempe, AZ, USA) (Figure 1H).
The right atrium was closed in two layers using 2-0 polypropylene suture. The cardiac chambers were covered using a patch of bovine pericardium.
Following systemic heparinisation, elective right femoral arteriovenous cannulation is done using long femoral arterial and venous cannulae (Edwards Lifesciences LLC, One Edwards Way, Irvine, CA, USA).
Under cardiopulmonary bypass, secondary median sternotomy was performed with the heart decompressed on bypass. The Dacron synthetic patch overlying the aorta, right ventricular outflow tract and superior vena cava was dissected.
The superior caval vein was dissected and cannulated directly using an angled metal tipped venous cannula and drained directly into the oxygenator. An 18-Fr sump suction vent was placed over the main pulmonary artery for further decompression of the heart to facilitate dissection. The intrapericardial inferior caval vein was dissected and looped for later occlusion.
The right pleural cavity was widely opened. Due to dense adhesions overlying the right and left atrium, the pericardium overlying body of the right atrium was not dissected. The patient was planned for transeptal approach of mitral re-replacement.
The aorta was cross-clamped using an atraumatic aortic vascular clamp. Myocardial preservation was achieved by integrated myocardial protection using direct osteal St. Thomas (II) based cold blood cardioplegia (4:1) and topical cardiac cooling using ice cold saline.
Successive doses of cardioplegia were repeated every 30 minutes.
After snugging the inferior caval vein, the pericardium overlying the right atrium was directly incised in between stay sutures. The interatrial septum was incised and opened in between stay sutures.
Two stay sutures of 2-0 Ethibond (Johnson and Johnson Ltd., Ethicon, LLC, San Lorenzo, USA) were placed over the prosthetic mitral annulus to facilitate later explantation of the mitral prosthesis.
An incision was made on the mitral prosthetic ring using a No.11 scalpel blade. The prosthetic valve was detached from the anterior atrioventricular groove by a combined sharp and blunt dissection.
A small right angle forceps was insinuated within the opening to facilitate explantation of the mitral prosthesis. The prosthetic valve was explanted by incising the prosthetic fibrous capsule on both atrial and ventricular surface. Extreme precautions were taken not to cause type I atrioventricular groove rupture. Precautions were also taken not the dislodge the thrombus contained within the prosthetic mitral valve. The posterior chordal apparatus was retained. The ventricular cavity is irrigated using cold normal saline.
Re-replacement of the mitral valve is done using a 29 mm St. Jude Mechanical prosthesis (St. Jude Medical; St Jude Medical; St. Paul, MN, USA) and interrupted 2-0 Ticron mattress suture.
The surgically created atrial septal defect was reconstructed using a Dacron polyester patch (Bard® Savage® filamentous knitted polyester fabric, Bard Peripheral Vascular Inc., Tempe, AZ, USA) (Figure 1H).
The right atrium was closed in two layers using 2-0 polypropylene suture. The cardiac chambers were covered using a patch of bovine pericardium.
Following systemic heparinisation, elective right femoral arteriovenous cannulation is done using long femoral arterial and venous cannulae (Edwards Lifesciences LLC, One Edwards Way, Irvine, CA, USA).
Under cardiopulmonary bypass, secondary median sternotomy was performed with the heart decompressed on bypass. The Dacron synthetic patch overlying the aorta, right ventricular outflow tract and superior vena cava was dissected.
The superior caval vein was dissected and cannulated directly using an angled metal tipped venous cannula and drained directly into the oxygenator. An 18-Fr sump suction vent was placed over the main pulmonary artery for further decompression of the heart to facilitate dissection. The intrapericardial inferior caval vein was dissected and looped for later occlusion.
The right pleural cavity was widely opened. Due to dense adhesions overlying the right and left atrium, the pericardium overlying body of the right atrium was not dissected. The patient was planned for transeptal approach of mitral re-replacement.
The aorta was cross-clamped using an atraumatic aortic vascular clamp. Myocardial preservation was achieved by integrated myocardial protection using direct osteal St. Thomas (II) based cold blood cardioplegia (4:1) and topical cardiac cooling using ice cold saline.
Successive doses of cardioplegia were repeated every 30 minutes.
After snugging the inferior caval vein, the pericardium overlying the right atrium was directly incised in between stay sutures. The interatrial septum was incised and opened in between stay sutures.
Two stay sutures of 2-0 Ethibond (Johnson and Johnson Ltd., Ethicon, LLC, San Lorenzo, USA) were placed over the prosthetic mitral annulus to facilitate later explantation of the mitral prosthesis.
An incision was made on the mitral prosthetic ring using a No.11 scalpel blade. The prosthetic valve was detached from the anterior atrioventricular groove by a combined sharp and blunt dissection.
A small right angle forceps was insinuated within the opening to facilitate explantation of the mitral prosthesis. The prosthetic valve was explanted by incising the prosthetic fibrous capsule on both atrial and ventricular surface. Extreme precautions were taken not to cause type I atrioventricular groove rupture. Precautions were also taken not the dislodge the thrombus contained within the prosthetic mitral valve. The posterior chordal apparatus was retained. The ventricular cavity is irrigated using cold normal saline.
Re-replacement of the mitral valve is done using a 29 mm St. Jude Mechanical prosthesis (St. Jude Medical; St Jude Medical; St. Paul, MN, USA) and interrupted 2-0 Ticron mattress suture.
The surgically created atrial septal defect was reconstructed using a Dacron polyester patch (Bard® Savage® filamentous knitted polyester fabric, Bard Peripheral Vascular Inc., Tempe, AZ, USA) (Figure 1H).
The right atrium was closed in two layers using 2-0 polypropylene suture. The cardiac chambers were covered using a patch of bovine pericardium.
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