This article has Open Peer Review reports available.
Non infective severe aortic paravalvular leakage 7 years after surgery: the role of suture technique
© Agrifoglio et al; licensee BioMed Central Ltd. 2011
Received: 5 November 2010
Accepted: 23 April 2011
Published: 23 April 2011
We report a case of redo aortic prosthesis replacement for a severe paravalvular leak (PVL) in a man operated with continuous suture technique 7 years earlier. The severe aortic regurgitation was due to the rupture of the suture. In spite of operations to replace malfunctioning heart valves are common procedures and performed all over the world from more than 50 years, there is still an open debate about the most suitable suture technique. In this case report, we'll discuss if the suture technique has a role in preventing or leading complications as severe PVL.
Paravalvular leak (PVL) after valve replacement is a rare, but serious complication. Most frequently PVL is caused by a prosthetic valve endocarditis, but it may also occurs without definite signs of infection. We report a case of redo aortic prosthesis replacement after 7 years from the operation and we discuss the role of suture technique in this case of severe paraprosthetic leak without any clearly infection signs.
A 48-year-old man came to our hospital for sudden effort dyspnea. The patient underwent seven years ago to aortic valve replacement (AVR) with 25 mm On-X (On-X Life Technology Inc., Austin, TX, USA) mechanical prosthesis for severe aortic valve regurgitation and ascending aorta replacement with a tube graft n 28 for ascending aorta aneurysm. The AVR was performed using three semicontinuous (2-0 Prolene, Ethicon, Somerville, NJ, USA) suture technique. The surgeon used three similar sutures with knots tied among them, hence the term semicontinuous. According to a "parachute technique" the sutures were suspended (left loose) to enable an easier suturing of the aortic annulus and sewing ring of the artificial valve prior to lower the prosthesis. Then a gentle alternate traction on the three semicontinuous sutures, usually with the help of a surgical nerve hook, is applied to pull up the redundant suture. This could weaken the suture and lead to its failure at a later date.
Preoperative 3 D, 24 slices, Computed Tomography Scan (CT-scan) showed perfect patency of coronary arteries and severe retrosternal adhesions.
AVR can be performed using either the semicontinuous or interrupted suture technique depending on the surgeons' choice. The undesired complication of PVL after AVR is a serious complication that can lead to heart failure, thromboembolic and hemolytic complications.
After valve replacement the factors that may mainly favor PVL formation are the annulus calcification and infections.
We report a case of paraprosthetic leakage, occurring seven years after AVR using a continuous suture technique. There are some controversies about the incidence of PVL with continuous suture technique. From one hand Englberger et al. reported an incidence of PVL of 5,8% , Hyelms et al. reported of 8,8% , Nair et al. even 12% in patients in whom a continuous suture was used . On the other hand Laks et coworkers  had incidence of PVL of only 2.3% and Qicai  surprisingly 0%. The advantages of the semicontinuous suture technique may consist in a shorter CPB, in a reduced myocardial ischemic injury time, and in shorter cross-clamping time, that may be of benefit in patients with poor left ventricular function. A shorter recovery could streghten the patients and may reduce also the occurrence of endocarditis after prosthetic valve implantation. An additional advantage of the continuous suture technique may be the presence of less thrombogenic material (pledgettes) around the prosthesis .
The advantages of interrupted sutures: you can avoid a complete, and sometimes, very dangerous decalcification, expecially when calcium is very close to coronary ostia or very deep in the ventricular septum or involving the anterior leaflet of mitral valve; the supraannular position permits a prosthesis oversizing to reduce the risk of patient mismatch, without increasing the risk of PVL.
At present TTE or TEE are now widely performed in patients after heart valve replacement. Recently three dimensional (3D) TTE has been introduced as non invasive tool reducing the need of TEE to describe and localize PVL. Actually, at this moment, it should be considered still complementary to two dimensional (2D) TTE and TEE [6, 7].
Small and asymptomatic paraprosthetic jets are often detected incidentally as a result of high sensitivity color flow mapping . These small leaks are at short term usually benign, but they require an accurate long-term follow-up for an early detection of a major paraprosthetic regurgitation that needs a second intervention.
Despite the annual aortic echocardiographic monitoring our patient had a sudden onset of dyspnea and a rapid cardiac failure caused by a non expected suture rupture.
For this reason an interrupted suture technique, as we usually do in our Department, could be the best choice to avoid a sudden, severe and sometimes life threatening complication as the rupture of almost one third of annulus suture line.
- Englberger L, Schaff H, Jamieson E, Kennard E, Im K, Holubkov R, Carrel T: Importance of implant technique on risk of major paravalvular leak (PVL) after St. Jude mechanical heart valve replacement: a report from the Artificial Valve Endocarditis reduction Trial (AVERT). Eur J Cardiothorac Surg. 2005, 28: 838-844. 10.1016/j.ejcts.2005.09.014.View ArticlePubMedGoogle Scholar
- Hyelms E, Vilhemsen R, Rygg T: Continuous suture technique in prosthetic aortic valve replacement. J Cardiovasc Surg. 1982, 23: 145-148.Google Scholar
- Nair S, Bhatnagar G, Valencia O, Chandrasekaran V: Effect of valve suture technique on incidence of paraprosthetic regurgitation and 10-Year survival. Ann Thorac Surg. 2010, 89: 1171-1179. 10.1016/j.athoracsur.2009.12.069.View ArticlePubMedGoogle Scholar
- Laks H, Pearl JM, Barthei SW, Elami A, Sorensen TJ, Milgalter E: Aortic valve replacement using a continuous suture technique. J Card Surg. 1993, 8: 459-465. 10.1111/j.1540-8191.1993.tb00394.x.View ArticlePubMedGoogle Scholar
- Qicai H, Zili C, Zhengfu H, Qicai H, Weiming Z, Zhoumiao C, Dingsheng Y, Bingtang Z: Continuous-suture technique in aortic valve replacement. J Card Surg. 2006, 21 (2): 178-10.1111/j.1540-8191.2006.00121.x.View ArticlePubMedGoogle Scholar
- Sade L, Uluçam M, Muderrisoglu H: Mitral Omnicarbon monoleaflet valve dehiscence mapped by 3D echocardiography. Eur J Echocardiogr. 2000, 9: 82-83.Google Scholar
- Yildiz M, Duran NE, Gokdeniz T, Kaya H, Ozkan M: The value of real time three dimensional transesophageal echocardiography in the assessment of paravalvular leak origin following prosthetic valve replacement. Arch Turk Soc Cardiol. 2009, 37 (6): 371-377.Google Scholar
- Ionescu A, Fraser AG, Butchart EG: Prevalence and clinical significance of incidental paraprosthetic valvar regurgitation: a prospective study using transoesophageal echocardiography. Heart. 2003, 89: 1316-1321. 10.1136/heart.89.11.1316.View ArticlePubMedPubMed CentralGoogle Scholar
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.