Treatment of syphilitic aortitis with coronary artery bypass grafting and "open" stent placement

Cardiovascular syphilis manifests many years after primary infection. Here, we report the successful treatment of a patient who developed syphilitic aortitis with bilateral coronary ostial stenosis and aortic insufficiency. The patient underwent right coronary artery bypass grafting, left main coronary ostial "open" stent placement, and mechanical aortic valve placement during open-heart surgery.

Mechanical Aortic Valve Thrombosis with Heart Failure Successfully Treated with Oral Anticoagulation: A Case Report

Background

The use of anticoagulation is mandatory for prevention of prosthetic valve thrombosis (PVT) worldwide, regardless of the valve type or position in the heart. In case a thrombosis causes symptomatic dysfunction, treatment usually includes the use of thrombolytic therapy or surgery. We report a case of PVT involving a patient with a mechanical aortic valve which was treated entirely with the use of anticoagulation therapy (warfarin).

Case Presentation

A 58-year-old man had an aortic valve replacement using a Carbomedics® mechanical valve due to severe aortic stenosis as a result of a calcific bicuspid native aortic valve. He was commenced on warfarin after surgery which was continued thereafter. He presented to our hospital after three years with shortness of breath at rest. On clinical examination, his condition was poor with a New York Heart Association functional classification of IV. He was in sinus rhythm and had an enlarged heart shadow on chest X-ray. Transesophageal echocardiography (TEE) revealed aortic valve regurgitation with vegetations on the anterior valve leaflet causing reduced hemi leaflet motility and a mean pressure gradient of 50 mmHg. Cinefluoroscopy revealed a dysfunctional mechanical valve leaflet. Surgery was at high risk of mortality due to the patient's clinical status and he was continued on warfarin therapy with close monitoring. Cinefluoroscopy and echocardiography done six months later revealed complete dissolution of thrombus and a normally functioning mechanical aortic valve.

Conclusion

Only a few cases of symptomatic, thrombotic mechanical aortic valve were entirely treated with anticoagulation only. Our patient is one such case who had resolution of symptoms and improvement on NYHA functional classification (IV to I).

Management of mechanical aortic valve thrombosis during the first trimester of pregnancy

BACKGROUND

Cardiovascular diseases are the leading cause of morbidity and mortality in pregnant women. On the other hand, cardiac surgery is not so common for pregnant women.

CASE REPORT

We present the case of a pregnant woman with diagnosed thrombosis of the mechanical aortic valve in the 12th gestational week. The patient underwent surgery, and successfully completed her pregnancy till the 37th gestational week.

CONCLUSION

We showed that, despite general anaesthesia during the first trimester of pregnancy, the application of the nonpulsatile flow of extracorporeal circulation and mild hypothermia, the operation was successfully completed and that both mother and fetus survived.

Passing a Mechanical Aortic Valve With a Short Tip Dilator to Facilitate Aortic Arch Endovascular Branched Repair

PURPOSE

To present a novel technique to successfully cross a mechanical aortic valve prosthesis.

TECHNIQUE

A 55-year-old female patient with genetically verified Marfan syndrome presented with a 5-cm anastomotic aneurysm of the proximal aortic arch after previous ascending aortic replacement due to a type A aortic dissection in 2007. The patient also underwent mechanical aortic valve replacement in 1991. A 3-stage hybrid repair was planned. The first 2 steps included debranching of the supra-aortic vessels. In the third procedure, a custom-made double branched endovascular stent-graft with a short 35-mm introducer tip was implanted. The mechanical valve was passed with the tip of the dilator on the lateral site of the leaflet, without destructing the valve and with only mild symptoms of aortic insufficiency, as one leaflet continued to work. This allowed the implantation of the stent-graft directly distally of the coronary arteries. Postoperative computed tomography angiography showed no endoleaks and patent coronary and supra-aortic vessels.

CONCLUSION

Passing a mechanical aortic valve prosthesis at the proper position is feasible and allows adequate endovascular treatment in complex arch anatomy. However, caution should be taken during positioning of the endovascular graft as the tip may potentially damage the valve prosthesis.

Prosthetic aortic valve thrombosis: To fibrinolyse or not to fibrinolyse? That is the question!

Prosthetic heart valve (PHV) dysfunction is a rare but serious complication whose optimal management may be challenging and requires a multidisciplinary approach. Treatment success ultimately depends on determining the underlying mechanism of valve dysfunction by echocardiography. However, being able to establish the main etiology is not always straightforward. We present a difficult case of obstructive PHV dysfunction and discuss clinical and echocardiographic parameters to help differentiate thrombus from pannus formation.

Tiara Valve Implantation in a Patient With Previously Implanted Mono-disk Mechanical Aortic Prosthesis

Transcatheter mitral valve replacement with the Tiara valve can be performed in inoperable patients with severe functional regurgitation. Risk of left ventricular outflow tract obstruction can be prevented using preoperative 3D imaging and 3D-printed models. However, in the case of mono-disk mechanical prostheses previously implanted in aortic position (Bjork-Shiley), there is an additional risk of mechanical interference leading to reduced leaflet motion and aortic valve dysfunction. Hereafter, we describe the case of a patient with a 27-mm mono-disk mechanical aortic valve implanted in 1978, a EuroSCORE II of 18%, and a Society of Thoracic Surgeon score (mortality) of 16% who successfully underwent a transapical Tiara valve implantation.

Optimal Intensity of Warfarin Therapy in Patients With Mechanical Aortic Valves

OBJECTIVE:

To review the current guidelines and published literature in order to identify the evidence-based international normalized ratio (INR) goal in patients with a mechanical aortic valve.

DATA SOURCES:

Medline/PubMed, Cochrane and Google Scholar database searches for relevant articles from 1946 through March 2017 were executed using the key words "mechanical aortic valve" and "antithrombotic therapy or anticoagulation therapy or warfarin."

STUDY SELECTION AND DATA EXTRACTION:

All English-language observational and interventional studies assessing INR goals in patients with a mechanical aortic valve were evaluated.

RESULTS:

After low thrombogenic valves became standard in the practice, the INR goal decreased to 2 to 3 in low-risk recipients with most of bileaflet mechanical aortic valves. There is a paucity of data to justify the INR goal of 2 to 3 in high-risk patients. Until further higher evidence is available, it is reasonable to target an INR range of 2.5 to 3.5 in patients with risk factors for thromboembolism with low thrombogenic valves, except for On-X valve. The INR goal in high-risk On-X aortic valve recipients can be managed at 1.5 to 2.5 with low-dose aspirin 3 months after valve implantation.

CONCLUSION:

The INR goals of 2 to 3 for low risk and 2.5 to 3.5 for high risk should be considered for bileaflet mechanical aortic valve recipients. Additionally, a lower INR goal of 2 to 3 for the first 3 months after valve replacement followed by an INR goal of 1.5 to 2.5 in both low- and high-risk aortic On-X valve recipients may be considered.

On-X versus St Jude Medical Regent mechanical aortic valve prostheses: early haemodynamics

Objective

We aimed to compare the early haemodynamic data of the On-X and St Jude Medical (SJM) Regent bileaflet mechanical prostheses in the aortic position.

Methods

A retrospective study was performed using data collected prospectively for a national database. Thirty-three patients who had aortic On-X valve (On-X group) and 33 matched patients who had aortic SJM Regent valve (SJM group) were included. The intraoperative and early postoperative data were collected. The same echocardiographer reviewed all the echocardiograms and obtained the required parameters.

Results

The peak gradient across the prosthetic valve was comparable between the two groups except for the labelled valve size of 25 mm for which the On-X group had lower peak gradient when compared with the SJM group. Mean gradients and effective orifice area indices of the two valve types within each valve size subgroup were comparable.

Conclusions

The current study confirms that in the early postoperative period, the two valve types had comparable haemodynamic outcomes.

Longest Event-Free Survival without Anticoagulation in a Mechanical Aortic Valve Replacement

Sixty percent of the patients going for valve replacement opt for mechanical valves and the remaining 40% choose bioprosthetics. Mechanical valves are known to have a higher risk of thrombosis; this risk further varies depending on the type of valve, its position, and certain individual factors. According to current guidelines, long-term anticoagulation is indicated in patients with metallic prosthetic valve disease. We report two unique cases of patients who survived 27 and 37 years event free, respectively, after mechanical aortic valve replacement (AVR) without being on any form of anticoagulation. The latter case described the longest survival in a human with a prosthetic aortic valve without anticoagulation. A review of literature demonstrated few cases of prosthetic valves with no anticoagulation in the long term without significant embolic events reported as case reports. These cases have been summarized in this article. Some cases of long-term survival (in the absence of anticoagulation) were attributed to good luck, and others as the result of genetic variations. New mechanical prosthetic valves can be promising, such as microporus-surfaced valves that may be used without full anticoagulation. The use of dual antiplatelet agents alone can be currently recommended only when a patient cannot take oral anticoagulation after AVR, and it should be followed with measuring and monitoring of platelet reactivity.