Transesophageal Echocardiographic Diagnosis of Acute Aortic Valve Insufficiency After Mitral Valve Repair

Abstract

Anesthesiologists are routinely required to evaluate cardiac valvular function by using transesophageal echocardiography (TEE) after valve replacement or repair. In addition to assessing the surgically corrected valve, evaluation of adjacent cardiac structures by using TEE is necessary to exclude iatrogenic surgical complications. Complications of mitral valve (MV) surgery that may be diagnosed by using TEE include injury to the ventricular septum, left ventricular outflow tract, and aortic valve (AV) (1–4). We report a case of acute AV insufficiency diagnosed by using TEE after MV repair. A 46-yr-old man with severe mitral regurgitation presented for elective MV surgery. Intraoperative TEE of the MV before cardiopulmonary bypass (CPB) revealed myxomatous leaflet degeneration, annular dilation, and ruptured posterior leaflet chordae tendineae. The AV was structurally normal (Fig. 1A) and without evidence of insufficiency. MV repair was subsequently performed by quadrangular resection of the posterior leaflet, sliding valvuloplasty, and placement of a 36-mm Carpentier-Edwards Physio annuloplasty ring (Baxter Healthcare Corp., Irvine, CA). TEE examination of the MV after CPB demonstrated only trace mitral regurgitation. However, the post-CPB TEE examination of the AV revealed a nonmobile left coronary cusp (Fig. 1B) and moderate insufficiency (Fig. 2). Surgical exploration of the aortic root revealed that a MV annuloplasty ring suture had perforated and tethered the AV left coronary cusp. Despite release of the tethering suture, the damaged AV leaflet was surgically unrepairable, necessitating AV replacement. This case highlights the importance of thoroughly examining adjacent cardiac structures by TEE after valvular surgery so that iatrogenic surgical complications may be diagnosed in a timely fashion.Figure 1: Midesophageal short-axis view of the aortic valve during systole. A, The AV leaflets appeared structurally normal and mobile before MV repair. B, The AV left coronary cusp was fixed and tethered (arrow) after MV repair. LA = left atrium, RA = right atrium, RV = right ventricle, NCC = noncoronary cusp, LCC = left coronary cusp, RCC = right coronary cusp.Figure 2: Midesophageal view of the AV and left ventricular outflow tract. Moderate AV insufficiency secondary to a fixed and tethered left coronary cusp after MV repair. LA = left atrium, LV = left ventricle, AV = aortic valve, AI = AV insufficiency, AMVL = anterior MV leaflet, AR = annuloplasty ring.Anne Rother MBBS, FANZCA* Brian Smith RDCS* David H. Adams MD† Charles D. Collard MD*