Intraoperative Failure of Pericardial Mitral Valve Requiring Emergent Reoperation Minutes After Replacement

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An 81-year-old woman with coronary artery disease, hypertension, ype 2 diabetes mellitus, and congestive heart failure (New York Heart ssociation class III) was admitted to the hospital with a history of ightheadedness and dyspnea. Cardiac catheterization showed severe riple-vessel coronary artery disease with complete occlusion of the left nterior descending, circumflex, and right coronary arteries. A TEE xamination revealed severe mitral annulus calcification, severe mitral egurgitation, mild aortic stenosis, mild aortic insufficiency, and a ormal ejection fraction. She was scheduled for an elective coronary rtery bypass graft surgery operation with a mitral valve replacement nder general anesthesia with standard and invasive monitoring includng an arterial catheter, pulmonary artery catheter, and transesophageal chocardiogram. The operative approach included a sternotomy, bicaval cannulation, nd retrograde cardioplegia. The patient first underwent coronary artery ypass graft surgery of her left anterior descending, first marginal, and econd marginal arteries with no complications. The mitral valve was xposed through a left atriotomy revealing degenerated valve leaflets nd severe annulus calcification. After the annulus was debrided, the nterior leaflet was excised, and the mitral orifice was sized for a no. 7-mm stented Carpentier-Edwards pericardial prosthesis (model 6900). Pledgeted annular sutures were placed through the sewing ring, ut the valve did not seat properly because of extensive annular alcification. On testing the valve with an intraventricular saline injecion, it was noted to be centrally incompetent without evidence of eaflet trapping. The prosthetic valve was removed, the annulus was ebrided, and a second larger stented pericardial prosthesis (29-mm; dwards Lifesciences, Irvine, CA) was seated and sutured with no ifficulty. After atrial closure, air was evacuated from the heart and the patient