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J Thorac Cardiovasc Surg 2000;119:857-856
© 2000 The American Association for Thoracic Surgery

LETTERS TO THE EDITOR

Posterior aortoventricular bleeding after aortic valve replacement with the stentless Cryolife-O’Brien valve

Service de Chirurgie Cardiothoracique, Hôpital Bichat, Paris, France

To the Editor

Mediratta, Sosnowski, and Galiñanes ¹ have pointed out the possibility of posterior aortoventricular bleeding after supra-annular aortic valve replacement with a stentless prosthesis. Such complications are directly related to extensive decalcification of the aortic anulus (along the left coronary part of the anulus).

We have now implanted nearly 400 Cryolife-O’Brien valves (Cryolife International, Atlanta, Ga) in our hospital, and posterior rupture occurred in two instances. The problem was revealed by uncontrollable bleeding before bypass had been discontinued. The surgical management was similar in both cases. We reclamped the aorta, arrested the heart, opened the aorta, and, approaching the valve, easily recognized the lesion below the left coronary cusp. The valve was removed along this area and the disruption repaired with a patch of pericardium. The valve was then reinserted in its previous position. The postoperative course was uneventful.

I would like to make several comments:

When fragilization of the anulus is recognized before valve implantation, it can be corrected with a small pericardial patch inserted around the area in question. This has been the case in three instances. Even with great experience, the surgeon may fail to recognize fragilization of the anulus before inserting the valve. Posterior bleeding has always occurred during bypass when the heart resumes its systolic ejection. Blind stitches from the outside may harm the valve leaflets, and I would not recommend that they be used.

A direct approach to the intra-aortic lesion in the safest and simplest way to deal with the problem.

The occurrence of anulus fragilization is rare and does not justify preventive stitching in all patients. Such stitches intended to reinforce the anulus may even harm the leaflets if abrasion is allowed to occur.

I am glad the authors shared their experience. Our two cases had not been reported, one of them occurring last October during a live teleconference.

12/8/105456 doi:10.1067/mtc.2000.105456

References

1. Mediratta N, Sosnowski AW, Galiñanes M. Posterior aortoventricular bleeding after supra-annular stentless aortic valve replacement. J Thorac Cardiovasc Surg 1999,117:1031-2.
   
2. Hvass U, O’Brien MF. The stentless Cryolife-O’Brien aortic porcine xenograft: a five-year follow-up. Ann Thorac Surg 1998, 66(6 suppl):S134-8.
   
3. Hvass U, Palatianos GM, Frassani R, Puricelli C, O’Brien MF. Multicenter study of stentless valve replacement in the small aortic root. J Thorac Cardiovasc Surg 1999;117:267-72.
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This Article Alert me when this article is cited Alert me if a correction is posted 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): Ulrik Hvass Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Hvass, U. Search for Related Content PubMed PubMed Citation Articles by Hvass, U.