Paravalvular Regurgitation After Implantation of a Suturelss Prosthesis Into a Degenerative Homograft
Iakovos Ttofi, Michael Murphy, David Mozalbat, John Pepper, Professor, George Asimakopoulos.
Royal Brompton Hospital, Royal Brompton & Harefield NHS Foundation Trust, London, United Kingdom.
Patient Demographics: Asymptomatic 56 year old man
Relevant History: The patient initially underwent AVR with a stented valve for bicuspid aortic stenosis complicated by endocarditis and homograft aortic root replacement. He re-presented with severe degenerative aortic valve regurgitation and preserved LV function ten years later.
Pre-Operative Plan: Femoral cannulation, re-sternotomy and implantation of a sutureless Perceval® prosthesis in view of severe annular calcification. A TAVI procedure was also considered but an open surgical approach was felt more appropriate because of his young age.
Discussion of what was actually done and the challenges, deaths and complications encountered. (Unless case is still pending): Following re-sternotomy and aortic cross clamping, severe calcification of the homograft was confirmed strengthening the indication to implant a sutureless prosthesis. The prosthesis was implanted easily and appeared well seated but resulted in immediate mild paravalvular regurgitation which was deemed acceptable. The patient had an uncomplicated post-operative recovery. The paravalvular regurgitation gradually became severe over the following 12 months while the patient remained asymptomatic. Echocardiography confirmed partial prolapsing of the valve into the left ventricle. The severity of the regurgitation prompted a further re-operation and replacement with a stented prosthetic valve. This was technically challenging but was achieved satisfactorily. The patient recovered well once again. This report constitutes our only case of long term severe paravalvular regurgitation following implantation of a sutureless valve. The sub-optimal positioning of the valve appeared to be due to the rigidity of the aortic valve annulus. Aortic root calcification remains one of the strongest indications for the use of a sutureless prosthesis but the shape of the annulus must be taken into consideration when the decision to implant the valve is being made. Furthermore, even mild paravalvular regurgitation at the end of the procedure should not be accepted. Subsequent cases of sutureless prostheses implanted into failing homografts in our institution remained uneventful.
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