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Early Postoperative Thrombosis of Pericardial Xenograft Aortic Valve

Department of Cardiovascular Surgery Hospital Universitario "Virgen de la Arrixaca" University of Murcia El Palmar, Murcia, Spain

For reprint information contact: Carlos-A Mestres, MD, PhD, FETCS Tel: 34 93 227 5515 Fax: 34 93 451 4898 email: cmestres{at}mx3.redestb.es Department of Cardiovascular Surgery, Hospital Clínic, University of Barcelona, Villarroel 170, Barcelona 08036, Spain.

	Abstract

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Thromboembolic complications and valve thrombosis in pericardial xenografts are rare. A case of early postoperative thrombosis of a pericardial xenograft is described.

	Introduction

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There is extensive experience of valve replacement using biological substitutes. Although controversy still exists regarding the use of mechanical or biological valves, advanced age, contraindications for anticoagulant therapy, or the possibility of pregnancy are considered adequate indications for using a biological valve substitute. The pericardial xenograft, now in its third generation, seems to perform extremely well, especially in the aortic position and in patients over 65 years of age.^1,2 Usually, no long-term anticoagulation is recommended and not all centers routinely prescribe anticoagulants in the first 3 months after surgery.^3,4 Thromboembolic complications are low, although the risk of thromboembolism appears to be greatest during the first 3 months after the operation.⁵ We report an uncommon case of early thrombosis of a pericardial xenograft in the aortic position, documented in the first postoperative week.

	Case Report

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A 66-year-old female complained of dyspnea on exertion and chest pain. She was diagnosed by two-dimensional echocardiography with Doppler analysis and color-flow mapping and cardiac catheterization, as having severe calcified aortic stenosis with normal coronary arteries. Elective surgery was recommended. She underwent aortic valve replacement with a 19-mm TAD Carpentier-Edwards pericardial xenograft (Baxter Healthcare Corp., Edwards Division, Santa Ana, CA, USA). The valve was rinsed three times by immersing it in normal saline and slowly rotating it, according to the manufacturer's protocol. Continuous antegrade and retrograde blood cardioplegia was used during the operation to protect the myocardium. The valve was implanted with 2/0 interrupted mattress braided sutures pledgeted with Teflon and inserted from the aortic side of the native annulus, as is the rule for most of our aortic implants. Before closing the aortotomy, the valve was inspected and there was no evidence of stent post distortion or restriction of leaflet motion. The operation was completed successfully and the patient was extubated within the first 24 hours as there were no signs of low cardiac output or arrhythmia and the blood gas analysis and biochemical profile were within normal limits. She was transferred to the ward where she started early ambulation. In accordance with our protocol for patients with a xenograft aortic valve replacement and in sinus rhythm, she was not given oral anticoagulants. On the 6th postoperative day, she suddenly collapsed while having breakfast. Cardiopulmonary resuscitation was unsuccess-ful. Postmortem examination showed a fresh thrombus on the aortic aspect of the xenograft, occluding the outflow (Figure 1).

View larger version (132K): [in this window] [in a new window]   Figure 1. Postmortem photograph of the aortic xenograft, showing a thrombus on the aortic aspect.

	Discussion

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The performance of the Carpentier-Edwards pericardial xenograft is extremely good in the aortic position, as can be seen in detailed studies with a follow-up of more than 10 years.^1,2 In our experience since 1992 when we started implanting this pericardial xenograft in the aortic position, hemodynamics are satisfactory and the complication rate is low. In this case, postmortem examination clearly indicated that the fresh thrombus on the aortic aspect of the xenograft was responsible for the death of the patient. We have not documented similar cases in our previous experience. The lack of anticoagulant therapy in the early postoperative period could have affected the outcome in this case, although there is some evidence that antiplatelet therapy might be more effective in preventing early thromboembolic events.⁸ Although we believe that this should be considered as a surgical exception, consideration of this case may be of interest to readers. This exceptional situation has not changed our policy of implanting the Carpentier-Edwards pericardial xenograft as the prosthesis of choice in elderly patients and in those with documented contraindications for anticoagulant therapy.

	References

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1. Cosgrove DM, Lytle BW, Taylor PC, Camacho MT, Stewart RW, McCarthy PM, et al. The Carpentier-Edwards pericardial aortic valve. Ten-year results. J Thorac Cardiovasc Surg 1995;110:651–62.[Abstract/Free Full Text]

2. Frater RW, Furlong P, Cosgrove DM, Okies JE, Colburn LQ, Katz AS, et al. Long-term durability and patient functional status of the Carpentier-Edwards Perimount pericardial bioprosthesis in the aortic position. J Heart Valve Dis 1998;7:48–53.[Medline]

3. Gharagozloo F, Mullany CJ, Orszulak TA. Early thrombotic stenosis of aortic bioprosthetic valves: report of two cases. Mayo Clin Proc 1993;68:703–5.[Medline]

4. Babin-Ebell J, Schmidt W, Eigel P, Elerto M. Aortic bioprosthesis without early anticoagulation. Risk of thromboembolism. Thorac Cardiovasc Surg 1995;43:212–4.[Medline]

5. Orszulak TA, Schaff HV, Puga FJ, Danielson GK. Risk of thromboembolism early following aortic valve replacement with the Carpentier-Edwards bioprosthesis. Circulation 1992;86(Suppl I):497.

6. Revuelta JM, Alonso C, Cagigas JC, Lequerica MA, Gaite L, Herrera S, et al. Long-term evaluation of the Ionescu-Shiley pericardial xenograft bioprosthesis in the aortic position. J Card Surg 1988;3:391–6.[Medline]

7. Masters RG, Pipe AL, Bedard JP, Brais MP, Goldstein WG, Koshal A, et al. Long-term clinical results with the Ionescu-Shiley pericardial xenograft. J Thorac Cardiovasc Surg 1991;101:81–9.[Abstract]

8. Aramendi JI, Agredo J, Llorente A, Larrarte C, Pijoán J. Prevention of thromboembolism with ticlopidine shortly after valve repair or replacement with a bioprosthesis. J Heart Valve Dis 1998;7:610–4.[Medline]

This Article Abstract Full Text (PDF) 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 Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Mestres, C.-A Articles by Fuentes, M. Search for Related Content PubMed Articles by Mestres, C.-A Articles by Fuentes, M.