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Page 4 of 5 Singh et al. Vessel Plus 2018;2:10 I http://dx.doi.org/10.20517/2574-1209.2018.18

Figure 3. Post-operative chest X-ray showing valve in the aortic position and peripherally inserted central catheter line

preventing oxidation and mitigating calcification;
2. Glycerolization with additional ethanol rinsing to reduce the residual chemicals and allowing the valves to
be packed dry as the glycerol and ethanol mixture displaces most of the water;
3. Sterilisation with ethylene oxide, thus valves need not be rinsed prior to usage.

In this randomized study, the valves were placed in the mitral position. The sheep with the novel
preservation had a lower mean gradient across the valve and less leaflet calcification. They concluded that the
novel preservation significantly improved the hemodynamic and anti-calcification properties compared to
current standard of care. This novel treatment led to the development of the INSPIRIS RESILIA valve. In its
recently published safety and efficacy trial (COMMENCE 2), the INSPIRIS RESILIA valve showed improved
breathlessness, increased effective orifice area, reduced mean gradient and low paravalvular leak rate at two
[6]
years. One-year actuarial freedom from all-cause mortality for all patients was 97.6% .
Our patient also has a long history of non-adherence to medication. This was taken into consideration
prior to deciding the choice of the valve to use. Retrospective analysis of the Veterans AffaiRs Study to
Improve Anticoagulation Registry demonstrated that patients with mental health conditions had a lower
[7]
time in therapeutic ratio after adjusting for other covariates . Mechanical heart valves also have an audible
click which has been shown to affect a patient’s health-related quality of life raising the likelihood of non-
[8]
adherence .
Ehler-Danlos syndrome is a genetic defect of collagen and connective tissue synthesis and structure. Our
patient had a recessively inherited form of EDS with an increased risk of cardiac valvular dysfunction. This
[9]
results in failure to synthesize proα2(I) chains of type I procollagen . Aortic regurgitation occurs by either
proximal aortic dilatation or laxity and redundancy of the aortic leaflets and mitral valve regurgitation
secondary to mitral valve prolapse. This alteration in valvular flow dynamics increases the risk of sub-acute
bacterial endocarditis (SBE). SBE has an insidious onset characterized by low-grade fever, night sweats, chills,
fatigability, malaise, weight loss and valvular insufficiency. Septic emboli may disseminate causing distal
infarcts or infections. Our patient had classical symptoms and a right foot cellulitis alongside splenic infarcts
from emboli. SBE is usually caused by the viridans group of streptococci. However, Streptococcus mutans is
rarely reported due to difficulties isolating and culturing the bacteria . Weinstein and Moellering first
[10]
[11]
published a case series of four patients with SBE and two with meningitis who were successfully treated with
penicillin and gentamicin. A similar treatment plan was employed in our patient with clindamycin for better
skin penetration due to the cellulitis that emerged.