A Rare Cause for Severe Mitral Regurgitation After Mitral Valve Replacement

Abstract

A 39-yr-old man with a history of biventricular heart failure presented for mitral and aortic valve replacement surgery. Mediastinal Hodgkin’s disease in his youth had been successfully treated by radiotherapy, but it resulted in a cardiomyopathy with calcification of the pericardium, myocardium, mitral valve, and aortic valve. Preoperative transesophageal echocardiography (TEE) revealed the following: severe mitral and aortic stenoses with mean gradients of 9 mm Hg and 50 mm Hg, respectively; mitral valve area 1.0 cm 2 ; aortic valve area 1.1 cm 2 ; moderatesevere mitral and aortic insufficiency, an estimated systolic pulmonary artery pressure of 55 mm Hg. Both left and right ventricular functions were visually estimated to be normal. Coronary angiography showed no relevant coronary artery disease. The patient underwent aortic and mitral valve replacements with bileaflet mechanical prostheses. After separation from cardiopulmonary bypass (CPB), the patient’s hemodynamics could not be stabilized, despite the administration of milrinone, epinephrine, and norepinephrine. TEE showed moderately impaired right ventricular function, whereas segmental and global left ventricular systolic functions were estimated as normal in the transgastric short-axis view. In the midesophageal views, the aortic valve prosthesis function was normal. In contrast, TEE analysis of the mitral valve prosthesis revealed severe regurgitation caused by immobilization of a valve leaflet in the open position [Figs. 1 and 2 (Please see