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DP01: RARE MULTIMODAL COMPLICATIONS DURING REDO AORTIC VALVE REPLACEMENT WITH HOMOGRAFT: IMPORTANCE OF IMMEDIATE INTRAOPERATIVE EVALUATION
Dylan Irvine, DO1; Aaron Hacker, DO2; Imani Thornton, MD1; Danielle Kumpf, MD2
1HCA Florida Westside Hospital; 2Cleveland Clinic Main Campus
Introduction: Aortic valve homografts are commonly selected for valve replacement because of favorable hemodynamics, durability, and relative resistance to thrombosis compared with other prosthetic valves. Redo homograft implantation is technically demanding and associated with distinct intraoperative challenges. Although uncommon, serious complications may occur and require immediate recognition. We describe a case of redo aortic valve replacement (AVR) with a homograft complicated by multiple intraoperative abnormalities, highlighting the importance of differentiating benign findings from those requiring prompt surgical intervention.
Methods/Case Presentation: A 69-year-old man underwent redo AVR (third sternotomy) after prior bioprosthetic valve replacement complicated by Staphylococcus epidermidis infective endocarditis. Preoperative transesophageal echocardiography (TEE) demonstrated severe paravalvular aortic regurgitation (circumferential extent 30.1%, pressure half-time 357 ms) and a left ventricular outflow tract (LVOT) pseudoaneurysm. Following homograft implantation, post–cardiopulmonary bypass TEE revealed new eccentric intravalvular aortic regurgitation with associated regional wall motion abnormalities in the right coronary artery (RCA) distribution. These findings raised concern for homograft leaflet prolapse into the RCA button, producing both regurgitant flow and dynamic coronary ostial obstruction. Cardiopulmonary bypass was reinitiated, and surgical inspection confirmed prolapse of the coronary cusp into the RCA ostium. The homograft was explanted and replaced. After reimplantation, post-bypass TEE demonstrated normal leaflet motion and resolution of wall motion abnormalities; however, a new mass was visualized within the LVOT. Further evaluation identified this structure as residual mitral valve apparatus tissue without evidence of LVOT obstruction. This finding was deemed benign and documented to prevent future misinterpretation as thrombus or vegetation.
Results/Discussion: In this case, intraoperative TEE directly guided recognition and management of multiple homograft-related abnormalities. Systematic evaluation confirmed valve seating, leaflet motion, and hemodynamic performance while identifying coronary cusp prolapse with ostial obstruction and residual paravalvular pathology. Homograft-specific considerations included assessment for geometric distortion, commissural malalignment, and regurgitation related to technically complex implantation. Although homografts are less thrombogenic and typically exhibit lower transvalvular gradients, they remain susceptible to early regurgitation and late calcific degeneration. Careful assessment of coronary ostial patency, hemostasis, and pericardial effusion was essential. Paravalvular leaks were identified by turbulent diastolic flow on color Doppler imaging. Residual regurgitation, pseudoaneurysm formation, coronary cusp prolapse, and retained mitral tissue represented a spectrum of abnormalities encountered during a single operative course.
Conclusion: Redo AVR with homograft implantation requires heightened intraoperative vigilance. Detailed TEE assessment and readiness for immediate surgical correction are essential for identifying both expected and rare complications and for guiding real-time surgical decision-making in this high-risk population.