Eur J Cardiothorac Surg 2003;23:1074-1075
© 2003 Elsevier Science NL
An alternative technique for non-infective paraprosthetic leakage repair
Andrea Moneta*,
Emmanuel Villa,
Francesco Donatelli
Cardiac Surgery Division, IRCCS Ospedale Maggiore di Milano, University of Milan, Milan, Italy
Received 19 December 2002;
received in revised form 6 March 2003;
accepted 11 March 2003.
* Corresponding author. Tel.: +39-02-4808-0333; fax: +39-02-4808-0635
e-mail: amoneta{at}milanocuore.org
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Abstract
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Severe paravalvular leak is generally a reason for the repetition of valve replacement surgery. On the contrary management of patients with mild and moderate defects is controversial. Long-term prognosis may be negatively affected if non-surgical strategy is adopted also in less symptomatic patients. The proposed technique of leak closure preserves the implanted prosthesis and may be useful in non-infective mild and moderate detachments. It may safely extend surgical treatment to less symptomatic patients suffering from this surgical complication.
Key Words: Cardiac surgery • Valve replacement • Paravalvular leak
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1. Introduction
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According to the literature, paraprosthetic leakage is a complication ranging from 2 to 17% [1]. Most frequently it is observed in mitral valve replacement with mechanical prosthesis [1,2]. Several factors may produce this complication including annular calcification, infection, suture technique, size and shape of prosthesis [1–3]. Generally related symptoms are fatigue, vertigo and dyspnea. Less frequently, patients are referred with heart failure and hemolysis. Redo surgery is generally required in case of severe impairment, but there is some evidence that also in less symptomatic patients surgical approach can reduce symptoms and the need for blood transfusions. Improved long-term survival is reported if aggressive strategy is adopted [2]. Currently used techniques are prosthesis replacement or conservative procedures with sutures or patch [1,2,4,5].
In this paper we describe a potentially useful technique for small and moderate non-infective detachments of mechanical or biological stented valves, implanted in either mitral or aortic position (in the figures only the aortic procedure is illustrated).
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2. Technique
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Re-entry (aortotomy, atriotomy) is performed as usual. In case of in-situ rotatable mechanical prosthesis, the valve (bileaflet or tilting disk) is rotated leaving the major valve opening in front of the leak site (Fig. 1)
. Often the dehiscence margins become fibrous and covered by thin friable tissue. Removal of detached sutures, pledgets and all the mobile friable material around the leak area is carefully carried out avoiding prosthesis cuff damage. The technique requires double-needle 2-0 unpledgeted braided sutures and at least two threads. A needle of each suture is passed into the annulus from the top to the bottom pushing with a suitable needle-holder, then it is dragged inside the ventricle through the prosthesis opening with a thin needle-holder and finally very gently driven outside avoiding leaflet damage (Fig. 1). Thereafter # 1 and # 2 sutures are tied together on a firm pledget and cut (Fig. 2)
. The free suture ends are pulled up until the pledget becomes fixed to the subvalvular structures (Fig. 2). The remaining needles are then passed in the sewing ring. The need for other pairs of sutures is evaluated before tying and after the leaflets motion is verified. Trans-esophageal echocardiography (TEE) is mandatory after cardiopulmonary bypass weaning. This repairing procedure is not suitable for small diameter mechanical prosthesis (17 and 19 mm).
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Fig. 1. Two double-needle 2-0 unpledgeted braided sutures are required. A needle of each suture is passed into the annulus, moved inside the ventricle through the prosthesis opening and then carefully driven outside.
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Fig. 2. Sutures are tied on a firm pledget and cut. The free suture ends are pulled up. When the pledget becomes fixed to the subvalvular structures, the remaining needles are passed in the sewing ring and sutures tied.
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Nine patients underwent operations with this technique from 1993 to 2001. Non-infective dehiscence was observed in five prosthetic mitral valves and in four aortic (respectively 4/5 and 4/4 mechanical bileaflets, 1/5 mitral biological valve) ranging 21–29 mm. Cardio-pulmonary bypass time was 31.9±7.0 and aortic cross-clamping time was 22.1±6.4 min. No damage to the prosthetic leaflet occurred. Intraoperative TEE showed leak absence in all cases and no hospital deaths occurred. At our Institution, in the same period three mitral prostheses were reimplanted and one valve was fixed with direct suture; in aortic position five leaks were sealed with different modalities and one prosthesis was changed.
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3. Comment
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Severe paravalvular leak is a frequent indication to reoperate and replacement of the implanted prosthesis is generally performed [1–3]. The management of patients with mild and moderate defects is controversial until they develop heart failure or hemolysis which are clear indications for reoperation. Early surgical approach has been suggested in less symptomatic patients because long-term prognosis may be negatively affected if medical strategy alone is adopted [2]. In addition to the prosthesis substitution, intraoperative possibilities are transmural stitches, patch curtaining of the leakage area, and rarely placement of a single everting U-shaped pledgeted suture. Homograft may be also be used in case of unreliable suture placement because of fragility or infection [4,5]. Transmural stitches through the ascending aorta are prevalently adopted in the non-coronary cusp location; in other areas repairing stitches may be fixed through the atria, the main pulmonary artery or the outflow tract of the right ventricle but more laborious or time-consuming strategies are required (for example unexpected dual venous cannulation, extensive dissection in redo surgery, opening of other cardiac cavities or vessels, conduction tissue injury risk). The proposed technique may offer the surgeon advantages in some circumstances: it seems simple, fast, versatile and allows extreme reduction of aortic cross-clamping time. This is particularly valuable if dysfunctioning hearts are operated on.
In conclusion this prosthesis conserving procedure is added to the available surgical options and may be useful in non-infective mild and moderate leaks. It may safely extend surgical treatment to less symptomatic or high risk patients.
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References
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- Hammermeister K., Sethi G.K., Henderson W.G., Grover F.L., Oprian C., Rahimtoola S.H. Outcomes 15 years after valve replacement with a mechanical versus a bioprosthetic valve: final report of the Veterans Affairs randomized trial. J Am Coll Cardiol 2000;36(4):1152-1158.[Abstract/Free Full Text]
- Genoni M., Franzen D., Vogt P., Seifert B., Jenni R., Kunzly A., Niederhauser U., Turina M. Paravalvular leakage after mitral valve replacement: improved long-term survival with aggressive surgery?. Eur J Cardiothorac Surg 2000;17(1):14-19.[Abstract/Free Full Text]
- Dhasmana J.P., Blackstone E.H., Kirklin J.W., Kouchoukos N.T. Factors associated with periprosthetic leakage following primary mitral valve replacement with special consideration of the suture technique. Ann Thorac Surg 1983;35(2):170-178.[Abstract]
- Williams T.E., Jr, Fanning W.J., Cattaneo S.M. Aortic paravalvular leaks: alternative suture placement strategy for the left coronary cusp. Ann Thorac Surg 1995;59(1):243-244.[Abstract/Free Full Text]
- Ersoy U., Pasaoglu I., Yilmaz M., Ates S. An alternative repair technique for aortic periprosthetic leakage. Eur J Cardiothorac Surg 1999;15:204-205.[Abstract/Free Full Text]
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Abstract
1. Introduction
