Objectives
The clinical implications of finding immobile leaflet(s) at the time of bioprosthetic
valve implantation but with acceptable prosthetic haemodynamics are uncertain. We
sought to determine the characteristics of such patients and their impact on outcome.
Methods
Patients with immobile leaflet at the time of surgical bioprosthetic valve implantation
were identified retrospectively by a systematic search of an institutional echocardiography
database (2010–2020). Intraoperative echocardiograms were reviewed de-novo to confirm
immobile leaflet(s) at the time of implantation. Cases were matched 1:2 to controls
with normal bioprosthetic leaflets motion for age, sex, prosthesis position, prosthesis
model, size, year of implantation, and pre-implantation left ventricular ejection
fraction. Proportional hazards method was used to analyse the composite endpoint of
stroke, valve thrombosis or re-intervention.
Results
Immobile leaflet at the time of bioprosthetic valve implantation were found in 26
patients (median age 71 ys 39% males) following tricuspid (n=13), mitral (n=11) and
aortic (n=2) valve replacements; 96% received porcine prostheses; prosthesis size
was 27 mm or larger in 92%. Immobile leaflet were recorded on intraoperative reports
in 16 (62%) cases. It resulted in elevated gradient or mild-moderate prosthetic regurgitation
in three (12%), but none led to immediate corrective action intraoperatively. At median
follow-up of 21 (4-50) months, presence of immobile leaflet was associated with composite
clinical endpoint of stroke, valve thrombosis or re-intervention (hazard ratio 6.8,
95% CI 1.8–25.2, p<0.01) compared to controls.
Conclusion
Immobile leaflet immediately post-bioprosthetic valve implantation is frequently under-recognised
intraoperatively and appears to be associated with early bioprosthetic dysfunction
and worse clinical outcome.
Keywords
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Article info
Publication history
Published online: March 23, 2022
Accepted:
February 16,
2022
Received in revised form:
January 18,
2022
Received:
October 23,
2021
Identification
Copyright
© 2022 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.
ScienceDirect
Access this article on ScienceDirectLinked Article
- Leaflet Immobility and Hypo-Attenuated Leaflet Thrombosis (HALT)–Under-Recognised Complications of Bioprosthetic Valve ReplacementsHeart, Lung and CirculationVol. 31Issue 8
- PreviewBioprosthetic leaflet immobility is under-recognised and is highlighted by an article by Naser et al. [1] in this edition of Heart, Lung and Circulation. The authors assert in their conclusions that “Immobile leaflet immediately post-bioprosthetic valve implantation is frequently under-recognised intra-operatively and appears to be associated with early bioprosthetic dysfunction and worse clinical outcome”. The valves assessed were predominantly porcine and while the number of cases is small, there was not much detail on the overall percent incidence of this issue.
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