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J Thorac Cardiovasc Surg 1994;108:185-187
© 1994 Mosby, Inc.

LETTERS TO THE EDITOR

Accelerated failure of bioprosthesis by entrapment in chordal-sparing mitral valve replacement

Department of Cardiovascular
Diseases (MBC-16)
King Faisal Specialist Hospital
P.O. Box 3354
Riyadh 11211, Saudi Arabia

To the Editor:

Preservation of annuloventricular continuity in mitral valve replacement has been shown experimentally ^1,2 and clinically ³ to be superior to the standard procedure with chordal resection. Although ideal in principle, this procedure is not totally free from complications. We report here the case of a patient with early failure of a Hancock II bioprosthesis in the mitral position as a consequence of a strut impinging on the posterior papillary muscle and chordae in a chordal-sparing operation.

A 75-year-old male patient underwent mitral valve replacement for degenerative prolapse of anterior and posterior cusps of the mitral valve. A 29 mm Hancock II valve (Medtronic Inc., Minneapolis, Minn.) was placed after disinsertion of the anterior cusp from the aortic curtain and use of it to buttress the sutures posteriorly. All chordae to the anterior and posterior leaflets were conserved. There were no postoperative complications. Follow-up echocardiogram at 12 months was reported as normal. At 24 months, the echocardiogram showed diminished valve area (1.5 cm ²) with no evidence of regurgitation. Severe prosthetic mitral regurgitation developed 2 months later, for which the patient underwent reoperation. At operation, the posterior strut of the bioprosthesis was found to be embedded in the posterior papillary muscle, preventing proper apposition of the cusps by separating them (Fig. 1). One of the cusps was torn at the free edge. The bioprosthesis was explanted and replaced with a 29 mm Hancock II valve after excision of all chordae tendineae. A retrospective review of the echocardiograms revealed that the structural distortion of the prosthesis was present from the early postoperative period (Fig. 2) in the systolic phase of the cardiac cycle.

View larger version (212K): [in this window] [in a new window]   Fig. 1. Explanted bioprosthetic valve. Arrow points to distortion caused by papillary muscle entrapment.

View larger version (93K): [in this window] [in a new window]   Fig. 2. Echocardiogram shows entrapment (arrow) in systolic phase of cardiac cycle.

Partial resection of the anterior cusp with resuspension of the upper edge of the cusp to the posterior anulus ⁵ and division of the anterior cusp with lateral plication of the two halves ⁶ are two of the techniques described for preserving the whole mitral valve apparatus. Concerns about the possibility of entrapment of a chord within the closing mechanism of a mechanical prosthesis have been reported, ⁷ but not when a bioprosthesis was used.

The fact that a Hancock II bioprosthesis was used in our case, with the rachet mechanism that joins the three struts at the time of implantation that should avoid the accidental entanglement of a suture, stresses this danger, which is even more likely with other bioprostheses. The report of this case is not intended to suggest abandoning this technique but rather to alert surgeons to this possible complication.

References

1. Gams E, Hagl S, Schad H, Heimisch W, Mendler N, Sebening F. Importance of the mitral apparatus for left ventricular function: an experimental approach. Eur J Cardiothorac Surg 1992;6(Suppl 1):S17-21.
   
2. Hansen DE, Cahill PD, Declampi WM, et al. Valvular ventricular interaction: importance of the mitral apparatus in canine left ventricular systolic performance. Circulation 1986;73:1310-20.[Abstract/Free Full Text]
   
3. Hennein HA, Swain JA, McIntosh CL, Bonow RO, Stone CD, Clark RE. Comparative assessment of chordal preservation versus chordal resection during mitral valve replacement. J THORAC CARDIOVASC SURG 1990;99:828-37.[Abstract]
   
4. Lillehei CW, Levy MJ, Bonnabeau RC Jr. Mitral valve replacement with preservation of papillary muscles and chordae tendineae. J THORAC CARDIOVASC SURG 1964;57:532-43.
   
5. David TE. Mitral valve replacement with preservation of chordae tendineae: rationale and technical considerations. Ann Thorac Surg 1986;41:680-2.[Abstract]
   
6. Okita Y, Miki S, Kusuhara K, et al. Analysis of left ventricular motion after mitral valve replacement with a technique of preservation of all chordae tendineae. J THORAC CARDIOVASC SURG 1992;104:786-95.[Abstract]
   
7. Borowski A, Reiss N, Klaer R. Intermittent obstruction of the Omnicarbon-valve prosthesis in the mitral position due to interference by papillary muscle: diagnostic and surgical considerations. J Cardiovasc Surg 1992;33:305-7.[Medline]
   

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This Article Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Ganga Prabhakar Zohair Al-Halees Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Prabhakar, G. Articles by Duran, C. M. G. Search for Related Content PubMed PubMed Citation Articles by Prabhakar, G. Articles by Duran, C. M. G.