Obstruction of Mechanical Mitral Prostheses: Analysis of Pathologic Findings

Vitale, Nicola; Renzulli, Attilio; Agozzino, L; Pollice, Alessio; Tedesco, Nicola; Schinosa, Luigi de Luca Tupputi; Cotrufo, Maurizio

doi:10.1016/s0003-4975(96)01391-4

Cited by 86 publications

(49 citation statements)

References 14 publications

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“…[9][10][11] Although the mechanism has not been clearly elucidated, the duration of pannus progression until reoperation was 9.9 ± 2.3 years in our series. Other Japanese report demonstrated that reoperation by pannus overgrowth rather than SVD was performed after 6 years from the initial operation.…”

Section: Discussionmentioning

confidence: 60%

Subvalvular Pannus Overgrowth after Mosaic Bioprosthesis Implantation in the Aortic Position

Hirota

Isomura

Yoshida

et al. 2016

ATCS

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IntroductionCurrently, the bioprosthetic aortic valve consisting of bovine pericardium or porcine aortic valve is one of standard and reliable substitutes for excellent hemodynamic performance and durability. 1,2) Satisfactory clinical outcomes were also achieved by the bioprostheses in patients younger than 70 years of age, although reoperations were required due to various causes such as structural valve deterioration (SVD). 3,4) Possible pathology of SVD included restriction of leaflet mobility by calcium deposition, and tear or perforation of the leaflet by mechanical stress over 10 years. In addition to these pathologies, pannus overgrowth was one of the coexisting alterations to affect valvular function, which was observed in 64% of explanted Hancock II porcine valve. 5) Although pannus overgrowth by itself was not the pathology of SVD, it might be related to reoperation for SVD despite improvement of anticalcification treatment for leaflets.We retrospectively reviewed patients undergoing reoperation for SVD after implantation of the third-generation Mosaic aortic bioprosthesis (Medtronic Inc, Minneapolis, Minnesota, USA). The macroscopic appearance of explanted valves was examined to detect the presence of pannus formation. Subvalvular Pannus Overgrowth after Mosaic Bioprosthesis Implantation in the Aortic PositionMasanori Hirota, MD, PhD, 1,2 Tadashi Isomura, MD, PhD, 1,2 Minoru Yoshida, MD, 2 Chieko Katsumata, MD, 1 Fusahiko Ito, MD, 1 and Masazumi Watanabe, MD 1 Purpose: Although pannus overgrowth by itself was not the pathology of structural valve deterioration (SVD), it might be related to reoperation for SVD of the bioprostheses. Methods: We retrospectively reviewed patients undergoing reoperation for SVD after implantation of the third-generation Mosaic aortic bioprosthesis and macroscopic appearance of the explanted valves was examined to detect the presence of pannus. Results: There were 10 patients and the age for the initial aortic valve replacement was 72 ± 10 years old. The duration of durability was 9.9 ± 2.0 years. Deteriorated valve presented stenosis (valvular area of 0.96 ± 0.20 cm 2 ; pressure gradient of 60 ± 23 mmHg). Coexisting regurgitant flow was detected in two cases. Macroscopically, subvalvular pannus overgrowth was detected in 8 cases (80%). The proportion of overgrowth from the annulus was almost even and pannus overgrowth created subvalvular membrane, which restricted the area especially for each commissure. In contrast, opening and mobility of each leaflet was not severely limited and pannus overgrowth would restrict the area, especially for each commissure. In other two cases with regurgitation, tear of the leaflet on the stent strut was detected and mild calcification of each leaflet restricted opening. Conclusion: In patients with the Mosaic aortic bioprosthesis, pannus overgrowth was the major cause for reoperation.

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Section: Discussionmentioning

confidence: 60%

Subvalvular Pannus Overgrowth after Mosaic Bioprosthesis Implantation in the Aortic Position

Hirota

Isomura

Yoshida

et al. 2016

ATCS

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“…Thrombosis is because of the deposition of clots on the prosthesis, and a pannus occurs because of an inflammatory reaction developing on both valve surfaces. 16 In our previous study reviewing the reoperation for cloth-covered S-E valves, there were 12 patients who required reoperation. 17 In the previous study, the mean interval at reoperation was 11.7 years, and marked cloth wear was observed in all aortic valves, but only slight wear in mitral valves.…”

Section: Discussionmentioning

confidence: 99%

Valve Dysfunction of the Cloth-Covered Starr-Edwards Ball Valve

Shiono

Sezai

Hata

et al. 2005

Circ J

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ince the first successful valve replacement using the original Starr-Edwards (S-E) caged silastic ball valve, some engineering modifications were made to enhance hemodynamic performance and fixation. The fabric covering was extended to the inflow orifice and then to the cage, and a silastic ball was changed to a stellite ball, which resulted in a group of "cloth-covered S-E ball valves". 1,2 Between June 1968 and March 1977, the clothcovered ball valves were used for aortic and mitral valve replacement (MVR) on a routine basis. Long-term results with the S-E ball valves have been reported showing satisfactory results with reliable durability and safety; they could represent the standard in mechanical valve replacement until recent prostheses can show a significant improvement in long-term results. However, reoperation after valve replacement with the S-E ball valve is unavoidable, and there have been only a few articles reporting detailed data concerning reoperations for the cloth-covered model of the S-E ball valve. The present study reports valve dysfunction and reoperation for the cloth-covered S-E ball prostheses. Methods PatientsThe cloth-covered S-E ball valves (aortic model 2300, 2310, 2320, and 2400, and mitral model 6300, 6310, 6320, and 6400) were implanted in the aortic and/or mitral position as the first choice for prosthetic substitution at our institution between June 1968 and March 1977. Oral anticoagulation regimens were administered after surgery and left at our outpatient clinic or local general practitioner's clinic. Among the 66 operative survivors who underwent an isolated aortic valve replacement (AVR; n=14) or MVR (n=52), 20 patients (11 male and 9 female) required reoperation 22 times because of valve dysfunction, thromboembolic complication, paravalvular leakage, hemolytic anemia, and/or prosthetic valve endocarditis. Reoperation was carried out at a mean of 15.9±9.8 years (range, 2.3 to 34.2 years) after initial valve replacement. The S-E valves were re-implanted 8 times in the aortic position (n=7; group A) and 14 times in the mitral position (n=13; group M) at a mean age of 44.7±13.9 years (range, 14 to 66 years). The S-E valves used at the initial operations and indications for reoperation are listed in Table 1. At reoperation, the heart was completely mobilized through a repeat median sternotomy and cardiopulmonary bypass was implemented through the femoral artery or the aorta for arterial perfusion, and right atrium for venous drainage. The patient's systemic temperature was cooled to 32°C and the heart was arrested using St Thomas' cold crystalloid cardioplegic solution. Care was taken during the prosthesis excision not to remove any structures from the prosthetic surfaces to avoid artificial changes on the prosthesis. The prosthetic valve was replaced using an interrupted method with braided polyester sutures or pledgeted polyester sutures at the supra-annular position.Excised valves were carefully examined, and morbidity after the initial and subsequent operations was defined

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“…The slow accretion of pannus can generate areas of flow stagnation and trigger the formation of a thrombus. Vitale over 56 cases of pannus leading to re-operation could find an associated thrombosis in 36 (64%) patients (13).…”

Section: Pannus Thrombus or Mismatchmentioning

confidence: 97%

“…At CT scan it is important to differentiate recent (fresh) from chronic (organized) thrombosis as the former is usually suitable for thrombolytic treatment which is the case when the attenuation is <90 HU (11)(12)(13)(14) (Figure 2).…”

Section: Pannus Thrombus or Mismatchmentioning

confidence: 99%

Use of multidetector-row computed tomography scan to detect pannus formation in prosthetic mechanical aortic valves

Aladmawi¹,

Pragliola²,

Vriz³

et al. 2017

J. Thorac. Dis.

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Aortic valve replacement (AVR) is the second most common cardiothoracic procedure performed in the United States (1) and Europe (2). Surgically or percutaneously implanted, the results of AVRs are uniformly good and the number of patients have been steadily increasing over the last decades (3). Although most of the newly implanted devices are tissue valves, yet a sizable number are mechanical especially in young patients with rheumatic disease. The latter group is predominant in non-Caucasian populations where the rheumatic disease is the most common aetiology (4).In parallel, during the same years computed tomography (CT) scan technology evolved substantially offering excellent resolution and the ability to identify the commonest and most challenging complications of AVR (5). In particular, ECG-gated CT scan proved to be more reliable than echocardiography in identifying pannus, the most insidious long-term complication of mechanical valves. CT scan techniqueImages are usually acquired using retrospective ECGgated protocols with cardiac phase reconstruction at 5% to 10% RR interval increments. Both systolic (at 20% to 40% of RR interval) and diastolic phase (at 70% to 90% RR interval) are usually necessary. With these modalities, more than 90% of the valves can be accurately evaluated (6). As opposed to retrospective triggering, prospective ECG-gated protocols tend to generate less artifacts and require lesser radiation doses. However, they can be used only in patients with regular heart rate. When the patients are in atrial fibrillation, short acting beta-blockers can be used during the acquisition phase. However, with faster heart rates best results are obtained with dual source CT scan.CT data are reconstructed by a separate workstation for post-processing where oblique coronal or oblique sagittal images of the aortic root are assembled (Figure 1). By using a multiplanar image technique, profile and enface views of the prosthetic aortic valve showing the least amount of motion artifacts are generated. The presence or absence of a subprosthetic pannus is determined by the examiner as the appearance of a low-attenuation lesion or a calcified lesion Abstract: Obstruction of a mechanical aortic valve by pannus formation at the subvalvular level is a major long-term complication of aortic valve replacement (AVR). In fact, pannus is sometime difficult to differentiate from patient-prosthesis mismatch or valve thrombosis. In most cases cine-angiography and echocardiography, either transthoracic or transesophageal, cannot correctly visualize the complication when the leaflets show a normal mobility. Recent technological refinements made this difficult diagnosis possible by ECG-gated computed tomography (CT) scan which shows adequate images in 90% of the cases and can differentiate pannus from fresh and organized thrombus.

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Obstruction of Mechanical Mitral Prostheses: Analysis of Pathologic Findings

Cited by 86 publications

References 14 publications

Subvalvular Pannus Overgrowth after Mosaic Bioprosthesis Implantation in the Aortic Position

Subvalvular Pannus Overgrowth after Mosaic Bioprosthesis Implantation in the Aortic Position

Valve Dysfunction of the Cloth-Covered Starr-Edwards Ball Valve

Use of multidetector-row computed tomography scan to detect pannus formation in prosthetic mechanical aortic valves

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