Valve Detachment After Aortic Valve Replacement

A 50-year-old Japanese male was admitted with a 1 month history of progressive shortness of breath, palpitations, and intermittent low-grade fever. On admission, a musical diastolic murmur (sea-gull murmur) was heard on the 3rd left sternal border. Blood studies showed an accelerated erythrocyte sedimentation rate, and positive C-reactive protein. Retrograde aortography revealed severe aortic regurgitation. At the operation, the aortic wall was remarkably thickened, and the aortic valve commissures between the right and left coronary cusps and between the left and non-coronary cusps had completely detached from the aortic wall. The aortic valve was replaced with a St Jude Medical valve using pledgeted sutures. Histologic studies of the aorta and aortic valve revealed no evidence of any pathologic changes. Echocardiography performed 82 days after aortic valve replacement showed severe paravalvular leakage and valve detachment. At the reoperation, the prosthetic valve was detached from the extremely edematous and fragile native aortic annulus. There was no vegetation or abscess formation. Aortic root replacement with the Cabrol technique was performed using a composite graft in which the prosthetic valve was placed 1 cm above the proximal extremity to reduce the tension on the suture line and the aortic annulus. Histologic study of the aorta after the reoperation showed non-specific inflammatory disease. The patient, who received steroid therapy, has recovered without any signs of graft detachment or pseudoaneurysm formation.