Advertisement
Heart, Lung and Circulation

Immobile Leaflets at Time of Bioprosthetic Valve Implantation: A Novel Risk Factor for Early Bioprosthetic Failure

A Novel Risk Factor for Early Bioprosthetic Failure
Published:March 23, 2022DOI:https://doi.org/10.1016/j.hlc.2022.02.011

      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

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Heart, Lung and Circulation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Barreto-Filho J.A.
        • Wang Y.
        • Dodson J.A.
        • Desai M.M.
        • Sugeng L.
        • Geirsson A.
        • et al.
        Trends in aortic valve replacement for elderly patients in the United States, 1999-2011.
        JAMA. 2013; 310: 2078-2085
        • Senage T.
        • Le Tourneau T.
        • Foucher Y.
        • Pattier S.
        • Cueff C.
        • Michel M.
        • et al.
        Early structural valve deterioration of Mitroflow aortic bioprosthesis: mode, incidence, and impact on outcome in a large cohort of patients.
        Circulation. 2014; 130: 2012-2020
        • Nitsche C.
        • Kammerlander A.A.
        • Knechtelsdorfer K.
        • Kraiger J.A.
        • Goliasch G.
        • Dona C.
        • et al.
        Determinants of bioprosthetic aortic valve degeneration.
        JACC Cardiovasc Imaging. 2020; 13: 345-353
        • Petrescu I.
        • Egbe A.C.
        • Ionescu F.
        • Nkomo V.T.
        • Greason K.L.
        • Pislaru C.
        • et al.
        Long-term outcomes of anticoagulation for bioprosthetic valve thrombosis.
        J Am Coll Cardiol. 2020; 75: 857-866
        • Agostoni P.
        • Buijsrogge M.P.
        • Stella P.R.
        "Frozen" leaflet: a dreadful complication of transcatheter aortic valve implantation.
        Circ Cardiovasc Interv. 2012; 5: 321-323
        • Thukral M.
        • Kanchuger M.
        Intraoperative failure of pericardial mitral valve requiring emergent reoperation minutes after replacement.
        J Cardiothorac Vasc Anesth. 2007; 21: 93-95
        • Pang P.Y.
        • Garwood S.
        • Hashim S.W.
        Intraoperative bioprosthetic valve dysfunction causing severe mitral regurgitation.
        Ann Thorac Surg. 2017; 103: e317-e319
        • Singh A.
        • Nanda N.C.
        • Kirklin J.K.
        Intraoperative transesophageal echocardiographic diagnosis of a stuck bioprosthetic mitral valve leaflet.
        Echocardiography. 2007; 24: 436-438
        • Goel S.
        • Monga N.
        • Majhi S.
        • Panigrahi B.
        • Sinha S.K.
        Intraoperative detection of a stuck bioprosthetic mitral valve leaflet causing severe mitral regurgitation.
        J Cardiothorac Vasc Anesth. 2011; 25: e44-e45
        • Couture E.L.
        • Labbe B.M.
        • DeLarochelliere R.
        • Rodes-Cabau J.
        • Paradis J.M.
        Stuck leaflet after transcatheter aortic valve replacement with a SAPIEN-3 valve: new valve, old complication.
        JACC Cardiovasc Interv. 2016; 9: e133-e135
        • Zoghbi W.A.
        • Chambers J.B.
        • Dumesnil J.G.
        • Foster E.
        • Gottdiener J.S.
        • Grayburn P.A.
        • et al.
        Recommendations for evaluation of prosthetic valves with echocardiography and doppler ultrasound: a report From the American Society of Echocardiography's Guidelines and Standards Committee and the Task Force on Prosthetic Valves, developed in conjunction with the American College of Cardiology Cardiovascular Imaging Committee, Cardiac Imaging Committee of the American Heart Association, the European Association of Echocardiography, a registered branch of the European Society of Cardiology, the Japanese Society of Echocardiography and the Canadian Society of Echocardiography, endorsed by the American College of Cardiology Foundation, American Heart Association, European Association of Echocardiography, a registered branch of the European Society of Cardiology, the Japanese Society of Echocardiography, and Canadian Society of Echocardiography.
        J Am Soc Echocardiogr. 2009; 22 (quiz 82-4): 975-1014
        • Lang R.M.
        • Badano L.P.
        • Mor-Avi V.
        • Afilalo J.
        • Armstrong A.
        • Ernande L.
        • et al.
        Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging.
        J Am Soc Echocardiogr. 2015; 28: 1-39.e14
        • Rusinaru D.
        • Bohbot Y.
        • Ringle A.
        • Marechaux S.
        • Diouf M.
        • Tribouilloy C.
        Impact of low stroke volume on mortality in patients with severe aortic stenosis and preserved left ventricular ejection fraction.
        Eur Heart J. 2018; 39: 1992-1999
        • Kukulski T.
        • She L.
        • Racine N.
        • Gradinac S.
        • Panza J.A.
        • Velazquez E.J.
        • et al.
        Implication of right ventricular dysfunction on long-term outcome in patients with ischemic cardiomyopathy undergoing coronary artery bypass grafting with or without surgical ventricular reconstruction.
        J Thorac Cardiovasc Surg. 2015; 149: 1312-1321
        • Egbe A.C.
        • Pislaru S.V.
        • Pellikka P.A.
        • Poterucha J.T.
        • Schaff H.V.
        • Maleszewski J.J.
        • et al.
        Bioprosthetic valve thrombosis versus structural failure: clinical and echocardiographic predictors.
        J Am Coll Cardiol. 2015; 66: 2285-2294
        • Egbe A.C.
        • Connolly H.M.
        • Pellikka P.A.
        • Schaff H.V.
        • Hanna R.
        • Maleszewski J.J.
        • et al.
        Outcomes of warfarin therapy for bioprosthetic valve thrombosis of surgically implanted valves: a prospective study.
        JACC Cardiovasc Interv. 2017; 10: 379-387
        • Makkar R.R.
        • Fontana G.
        • Jilaihawi H.
        • Chakravarty T.
        • Kofoed K.F.
        • De Backer O.
        • et al.
        Possible subclinical leaflet thrombosis in bioprosthetic aortic valves.
        N Engl J Med. 2015; 373: 2015-2024
        • Imamura E.
        • Ohteki H.
        • Tsutsui T.
        • Nishiya Y.
        • Ishihara S.
        • Koyanagi H.
        Open versus closed position fixation of bioprosthesis. Comparative in vitro studies from the viewpoint of durability.
        J Thorac Cardiovasc Surg. 1982; 83: 610-617
        • Imamura E.
        • Kaye M.P.
        • Davis G.D.
        Radiographic assessment of leaflet motion of Gore-Tex laminate trileaflet valves and Hancock xenograft in tricuspid position of dogs.
        Circulation. 1977; 56: 1053-1058
        • Sengupta P.P.
        • Narula J.
        TAVR-related complications why did we forget the design of a normal aortic valve?.
        Jacc-Cardiovasc Imag. 2017; 10: 100-103

      Linked Article