Our Summary

This research paper discusses a surgical procedure performed on a 71-year-old man with a tracheostomy (a hole made in the neck to help breathing). The man needed his aortic valve replaced again due to structural problems in the replacement valve. He had previously had an aortic valve replacement procedure, known as the Bentall procedure. He also had other health issues, including kidney failure needing regular dialysis.

About a year after the Bentall procedure, the man had breathing problems and heart failure, requiring mechanical assistance to breathe. He was then moved to another hospital for intubation (inserting a tube into his throat to help him breathe). He also developed a severe lung infection, requiring antibiotics and a tracheostomy. An echo scan showed serious backflow of blood in the aortic valve due to issues in the replacement valve’s structure.

Performing a full sternotomy (opening up the chest) in a patient with a tracheostomy could lead to an infection in the mediastinum (the space between the lungs); hence, the doctors decided to replace the aortic valve through a lower hemisternotomy (opening up the lower part of the chest). The surgery to replace the aortic valve went well, with the old replacement valve removed while keeping the blood vessel graft from the previous Bentall procedure.

After the surgery, the man recovered without any issues and was discharged from the hospital 31 days after closing the tracheostomy. This case shows that replacing the aortic valve through a lower hemisternotomy can be successful in patients with structural valve problems who are at risk of further surgical complications.

FAQs

  1. What is the risk associated with a full sternotomy in patients with a tracheostomy?
  2. What is the alternative surgical procedure for patients with a tracheostomy who need aortic valve replacement?
  3. What was the outcome of the reoperative aortic valve replacement (re-AVR) performed through a lower hemisternotomy in the case described?

Doctor’s Tip

One helpful tip a doctor might tell a patient about aortic valve replacement is to follow all postoperative care instructions carefully, including taking prescribed medications, attending follow-up appointments, and participating in cardiac rehabilitation if recommended. It is important to monitor for any signs of infection, such as fever, increased pain, redness, or swelling at the incision site, and to seek medical attention if any concerning symptoms arise. It is also important to maintain a healthy lifestyle, including regular exercise, a balanced diet, and avoiding smoking, to promote overall heart health and reduce the risk of complications.

Suitable For

Patients who are typically recommended for aortic valve replacement include those with severe aortic stenosis or regurgitation, symptomatic heart failure, or reduced left ventricular function. Other factors that may indicate the need for aortic valve replacement include recurrent chest pain, heart rhythm abnormalities, and poor exercise tolerance. Additionally, patients with structural valve deterioration (SVD) or prosthetic valve endocarditis may also require aortic valve replacement. In some cases, patients who have previously undergone aortic valve replacement may require reoperative aortic valve replacement due to valve dysfunction or other complications.

Timeline

  • Patient undergoes Bentall procedure with bioprosthetic valve for enlarged ascending aortic aneurysm
  • 14 months post-Bentall procedure, patient presents with sudden dyspnea, acute heart failure, and severe pneumonia
  • Patient undergoes tracheostomy and receives antibiotic medication for pneumonia
  • Echocardiography reveals severe aortic regurgitation from structural valve deterioration
  • Reoperative aortic valve replacement (re-AVR) performed through lower hemisternotomy to avoid risk of mediastinitis
  • Bioprosthetic valve is removed and vascular graft from previous Bentall procedure is preserved during surgery
  • Postoperative course is uneventful and patient is discharged from hospital 31 days after tracheostomy is closed

What to Ask Your Doctor

  1. What is the reason for needing an aortic valve replacement?
  2. What are the risks and benefits of the procedure?
  3. What type of valve will be used for the replacement (mechanical or biological) and why?
  4. What is the expected recovery time and rehabilitation process?
  5. Will there be any restrictions or lifestyle changes needed after the surgery?
  6. What are the potential complications or risks associated with the surgery?
  7. How long will the new valve last and will additional surgeries be needed in the future?
  8. What is the success rate of this procedure in patients with similar medical history?
  9. Will I need to continue taking any medications after the surgery?
  10. Are there any alternative treatment options available?

Reference

Authors: Katsumata K, Kawai Y, Ito T, Shimizu H. Journal: Keio J Med. 2023 Mar 25;72(1):21-25. doi: 10.2302/kjm.2022-0009-CR. Epub 2023 Jan 19. PMID: 36653143