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 Table of Contents  
Year : 2020  |  Volume : 4  |  Issue : 1  |  Page : 36-38

Very Early and Unusual Aortic Bioprosthetic Valve Deterioration 9 Months after Implantation

Department of Cardiology, Jaipur Golden Hospital, Delhi, India

Date of Submission03-Aug-2019
Date of Acceptance17-Aug-2019
Date of Web Publication11-Apr-2020

Correspondence Address:
Prof. Jagdish C. Mohan
Institute of Heart and Vascular Diseases, Jaipur Golden Hospital, Sector 3, Rohini, Delhi - 110 088
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jiae.jiae_37_19

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Every component of valvular bioprostheses is prone to variable structural deterioration secondary to multifactorial etiopathogenesis. Calcific degeneration is the most common phenomenon. However, it is a slow process in the elderly and typically starts after several years of implantation. We herein report a very early bioprosthesis deterioration of unknown etiology due to inward bending of the stent posts (“stent creep”) causing severe aortic stenosis. Nine months after aortic valve replacement with a 21-mm Epic Supra bioprosthesis (St. Jude Medical, St. Paul, MN, USA) with concomitant coronary artery bypass grafting and carotid endarterectomy, valve orifice narrowing with leaflet restriction and markedly reduced geometric orifice of the outflow causing severe valvular stenosis was documented in a 72-year-old man. A possible reason for this extremely early deterioration was circumferential compression of the bioprosthesis stent causing inward bending of the stent posts. The patient refused redo surgery and continued to be symptomatic with dyspnea for the next 2 years till his demise.

Keywords: Aortic valve replacement, bioprosthesis degeneration, Epic Supra biological valve, stent creep

How to cite this article:
Shukla M, Mohan V, Mohan JC. Very Early and Unusual Aortic Bioprosthetic Valve Deterioration 9 Months after Implantation. J Indian Acad Echocardiogr Cardiovasc Imaging 2020;4:36-8

How to cite this URL:
Shukla M, Mohan V, Mohan JC. Very Early and Unusual Aortic Bioprosthetic Valve Deterioration 9 Months after Implantation. J Indian Acad Echocardiogr Cardiovasc Imaging [serial online] 2020 [cited 2020 Aug 14];4:36-8. Available from: http://www.jiaecho.org/text.asp?2020/4/1/36/282203

  Introduction Top

There is an increasing trend about the use of bioprosthetic valves in the elderly because of their low thrombogenicity and minimal need for anticoagulation. However, structural deterioration and limited durability are major concerns. Structural deterioration usually presents not only as leaflet calcification resulting in stenosis but also as leaflet flail or tear resulting in regurgitation. Structural degeneration is uncommon in the elderly at least in the first few years. Midterm failure rates of porcine and bovine bioprostheses are quite low: <1% before 5 years and 10% at 10 years for patients > 65-year-old.[1] The Epic stented porcine prosthesis (St. Jude Medical, St. Paul, MN) in the aortic position has demonstrated excellent hemodynamic performance[2],[3] and durability.[4],[5] It has a relatively rigid stent of silicone elastomer covered by knitted polyester fabric, and its porcine aortic valve leaflets are treated by Linx AC technology which is claimed to prevent calcification by reducing free aldehydes, extracting lipids, minimizing uptake of cholesterol, and stabilizing collagen.[6] Low rates of valve-related events and structural failure prove that the Epic bioprostheses is a good choice for patients with calcified aortic stenosis. Degeneration of bioprostheses usually occurs rather late in an age-dependent manner.[4],[5] Therefore, aortic valve replacement with an Epic Supra bioprosthesis is a reliable option, especially for elderly patients. We describe a 72-year old patient with early valve deterioration of a St. Jude Medical Epic Supra aortic bioprosthesis 9 months' postoperatively with a peculiar phenomenon of bioprosthetic stent postdeformation.

  Clinical Presentation Top

This 72-year-old man underwent 3-vessel coronary artery bypass surgery, left carotid endarterectomy, and aortic valve replacement with #21 Epic Supra (St Jude Medical, St Paul, MN, USA) on April 17, 2013. He suffered from inferior wall infarction 2 years before surgery. During this period, he was documented to have intermittent left bundle branch block, normal left ventricular function, and calcified degenerative aortic valve stenosis (peak gradient of 40 mmHg and valve area of 0.8 cm2). Following surgery, he experienced Class II dyspnea from July 2013. He was also diagnosed with paroxysmal atrial fibrillation and treated with Vitamin K antagonist with nearly therapeutic international normalized ratio (INR) most of the times. He underwent a detailed echocardiographic examination on January 29, 2014 (9 months after valve replacement) for persistent dyspnea. He had Doppler features of Grade 2 diastolic dysfunction, E/e' of 30 mmHg, estimated left ventricular ejection fraction of 0.57, pulmonary systolic pressure of 55 mmHg and mild mitral regurgitation. Peak and mean transprosthetic systolic gradients were 68 mmHg and 43 mmHg with estimated valve area of 0.8 cm2 [stroke volume 75 mL, aortic velocity-time integral of 110 cm and peak velocity of 4.3 m/s, [Figure 1]. We noticed thickened stent posts with inward bending and narrow geometric orifice [Figure 2] in transthoracic examination commissural fusion and leaflet restriction concentrated around the posts in the outflow portion [Figure 1]. There was inward bending of all three stent posts [Figure 1]. The stent posts did not show any mobility. No tear or perforation was seen. No thrombus-like structure could be visualized. Geometric orifice area was significantly reduced due to its impingement by stent posts although the leaflets appeared thin and pliable in transesophageal echocardiography [Figure 2], [Figure 3], [Figure 4]. No pannus was seen. There were minimal aortic regurgitation and no prosthetic dehiscence. Anticoagulation was intensified to keep INR above 2.5 and 75 mg aspirin was added. Serial echocardiographic follow-ups showed almost similar observations with a slight decrease in transprosthetic gradients on April 2015. However, the gradients and valve area on February 2016 were similar to that recorded on January 2014 [Table 1]. He died in Mid-2016 after refusing repeat surgery.
Figure 1: Transprosthetic peak gradient of 74 mmHg and mean gradient of 42.5 mmHg with an estimated prosthetic valve area of 0.7 cm2. Recorded on February 16, 2016. (a) Shows narrowed colour Doppler jet across the prosthesis and (b) shows marked bending of the stent posts impingingon the outflow tract

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Figure 2: Transesophageal biplane views showing stent posts in the outflow portion. Right panel shows narrow oval orifice due to commissural restriction caused by impingement of orifice by the stent posts

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Figure 3: Narrow oval orifice of the aortic bioprosthesis (a) and protruding posts (b) seen from the left ventricle side in three-dimensional echocardiography

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Figure 4: Inward bending of the stent posts with relative fixity seen in transesophageal long axis views during systole and diastole

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Table 1: Serial Doppler hemodynamic data of the patient

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  Discussion Top

Refinements in bioprosthetic valve technology have greatly improved the hemodynamics and durability of these valves. Nevertheless, early structural failures do occur.[7],[8],[9] In the 2009, the American Society of Echocardiography recommendations for the evaluation of bioprosthetic aortic valves,[10] possible stenosis was defined as peak prosthetic aortic jet velocity 3–4 m/s, mean gradient 20–35 mmHg, and effective orifice area 0.8–1.2 cm2. Significant stenosis was defined as peak prosthetic aortic jet velocity >4 m/s, mean gradient >35 mmHg, and effective orifice area <0.8 cm2. Our patient met the criteria for significant stenosis 9 months after implantation. There was evidence of both hemodynamic and morphological deterioration. However, the leaflets were normal in morphology, although the restricted opening was seen due to inward bending of the stent posts.

The stent of Epic Supra is covered with knitted polyester fabric. The sewing cuff on Epic standard valves is formed from a braided polyester filler material that is covered by the knitted polyester fabric cover. The sewing cuff on Epic Supra valves is formed by enclosing a molded silicone elastomer within the same knitted polyester fabric.[6] “Stent Creep” seen in some bioprostheses is due to inward bending of the stent struts.[11] It may or may not be obvious on echocardiographic imaging, but increases the transvalvular gradient as measured by Doppler echocardiography. Stent creep tends to increase with time after implantation.[12] It is due to an ultrastructural deformity of polypropylene used in the valve stent.[12] The mechanism of stent postdeformity was suggested to be circumferential compression caused by bioprosthetic-ventricular or bioprosthetic-aortic disproportion in some cases.[11],[12] In addition to this mechanism, the stent postdeflection during diastole in the aortic position was reported to result in stent creep. Stent postcompression by the circumferential ascending aortic or left ventricular wall is acceptable as one of the mechanisms leading to stent creep. It has been proposed that stent postdeformity is a noncritical issue in performance of bioprosthetic like Epic, which is rigid and shows minimum deformity.[13],[14] In this study,[14] Radial deformity of Epic xenoaortic bioprosthesis was just 1.2%.

  Conclusion Top

Our patient is an example of significant stent creep in the Epic valve, which resulted in significant valvular obstruction. The patient was offered a valve-in-valve solution by a percutaneous approach, but he declined this procedure.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Nishida T, Tominaga R. A look at recent improvements in the durability of tissue valves. Gen Thorac Cardiovasc Surg 2013;61:182-90.  Back to cited text no. 1
Maitland A, Hirsch GM, Pascoe EA. Hemodynamic performance of the St. Jude medical epic supra aortic stented valve. J Heart Valve Dis 2011;20:327-31.  Back to cited text no. 2
Ruzicka DJ, Eichinger WB, Hettich IM, Bleiziffer S, Bauernschmitt R, Lange R, et al. Hemodynamic performance of the new St. Jude medical epic supra porcine bioprosthesis in comparison to the medtronic mosaic on the basis of patient annulus diameter. J Heart Valve Dis 2008;17:426-33.  Back to cited text no. 3
Lehmann S, Walther T, Leontjev S, Kempfert J, Rastan A, Garbade J, et al. Mid-term results after epic xenograft implantation for aortic, mitral, and double valve replacement. J Heart Valve Dis 2007;16:641-8.  Back to cited text no. 4
Jamieson WR, Lewis CT, Sakwa MP, Cooley DA, Kshettry VR, Jones KW, et al. St Jude medical epic porcine bioprosthesis: Results of the regulatory evaluation. J Thorac Cardiovasc Surg 2011;141:1449-5400.  Back to cited text no. 5
Epic™ valve [Package Insert]. Chicago, IL: Abbott; [Table 1].  Back to cited text no. 6
Kalra A, Rehman H, Ramchandani M, Barker CM, Lawrie GM, Reul RM, et al. Early trifecta valve failure: Report of a cluster of cases from a tertiary care referral center. J Thorac Cardiovasc Surg 2017;154:1235-40.  Back to cited text no. 7
Dohi M, Doi K, Yaku H. Early stenosis of an aortic porcine bioprosthesis due to thrombosis: Case report and literature review. J Thorac Cardiovasc Surg 2015;149:e83-6.  Back to cited text no. 8
Wiedemann D, Bonaros N, Laufer G, Kocher A. Aortic bioprosthetic valve deterioration 8 months after implantation. Ann Thorac Surg 2010;89:277-9.  Back to cited text no. 9
Zoghbi WA, Chambers JB, Dumesnil JG, Foster E, Gottdiener JS, Grayburn PA, 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;22:975-1014.  Back to cited text no. 10
Salomon NW, Copeland JG, Goldman S, Larson DF. Unusual complication of the Hancock porcine heterograft: Strut compression in the aortic root. J Thorac Cardiovasc Surg 1979;77:294-6.  Back to cited text no. 11
Borkon AM, McIntosh CL, Jones M, Roberts WC, Morrow AG. Inward stent-post bending of a porcine bioprosthesis in the mitral position: Cause of bioprosthetic dysfunction. J Thorac Cardiovasc Surg 1982;83:105-7.  Back to cited text no. 12
Kalejs M, Stradins P, Lacis R, Ozolanta I, Pavars J, Kasyanov V, et al. St Jude epic heart valve bioprostheses versus native human and porcine aortic valves-comparison of mechanical properties. Interact Cardiovasc Thorac Surg 2009;8:553-6.  Back to cited text no. 13
Kalejs M, Lacis R, Kasyanov V, Ozolanta I, Sayed PA, Stradins P, et al. Comparison of radial deformability of stent posts of different aortic bioprostheses. Interact Cardiovasc Thorac Surg 2013;16:129-33.  Back to cited text no. 14


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

  [Table 1]


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