Complication Of Mitral Valve Replacement Research Articles

Case of the Season: Gerbode Defect and Left Ventricular Pseudoaneurysm as Complications of Mitral Valve Replacement

Case of the Season: Gerbode Defect and Left Ventricular Pseudoaneurysm as Complications of Mitral Valve Replacement

C36 NON–CYCLIC INTERMITTENT PROSTHETIC MITRAL VALVE DYSFUNCTION: A CASE REPORT OF A DIFFICULT DIAGNOSIS CONFIRMED WITH MULTIMODALITY IMAGING

Abstract A 59–year–old man,obese,with history of hypertension, 3 years ago underwent mitral valve (MV) replacement with a mechanical prothesis(Sorin Bicarbon 31) and preservation of the native subvalvular apparatus for severe mitral regurgitation due to anterior leaflet flail. Pre–discharge transthoracic echocardiography (TTE) showed normal prothesis function (mean pressure gradient (PG) 3,2mmHg), no valvular leaks and a normal ejection fraction (EF). Lately, the patient was admitted twice to emergency department for signs of heart failure, solved with increasing dose of oral diuretics. In both cases a TTE showed a normal EF, a trans–prosthetic mean PG of 6,5mmHg and no valvular impairment/leaks. Since the suboptimal TTE acoustic windows, a transesophageal echocardiography (TEE) was recommended. TEE showed a normal motion of both MV discs and no pannus/thrombus or leaks with the use of a 2–beat acquisition protocol. However, with longer observation a pattern of non–cyclic intermittent valve dysfunction was noted: whereas some cardiac cycles showed normal discs’ motion, other cycles demonstrated an emi–disc opening delay or blockage during diastole with significant prolongation of transmitral pressure half–time and higher transvalvular gradient, suggestive of flow impairment. A cine fluoroscopy and a CT assessment were also performed, showing the visible intermittent pattern of valve dysfunction without radiological signs of thrombosis or pannus. At this point, the interference of the MV apparatus with the emidisc was considered the most probable mechanism of dysfunction. A Heart Team decision toward reintervention was taken since the risk of a sudden worsening of the mechanical valve function, with potentially lethal consequences, was considered high. The surgeon at visual inspection confirmed the interference of the subvalvular apparatus with the posterior emidisc motion. The chronic shear stress generated on the mitral remnant likely developed a progressive fibrotic response that determined the thickening of the tissue and the periodical entrapment of the disc. MV prothesis was replaced with resection of the subvalvular apparatus. At dismissal,TTE evaluation showed normal valvular function confirmed at 6 months follow–up. Intermittent prosthetic MV dysfunction is a rare but potentially serious complication of MV replacement with subvalvular apparatus preservation. TEE, cine–fluoroscopy and CT may be useful as complementary tools to detect this rare complication.

Repair of atrioventricular disruption after mitral valve replacement utilizing commando procedure principles.

Atrioventricular rupture is a life-threatening complication of mitral valve replacement. We present how incising the intervalvular fibrosa critically improves exposure. The aortic valve sacrifice allows access to a large atrioventricular dissociation defect and reliable repair of the anterolateral aspect of mitral valve annulus.

Novel Surgical Technique to Prevent Left Ventricular Rupture After Mitral Valve Replacement

Left ventricular rupture, also called atrioventricular disruption, remains a rare but lethal complication of mitral valve replacement. Available measures for preventing such a complication are limited to preservation of the posterior mitral leaflet and avoidance of overzealous decalcification of the annulus. Moreover, these strategies are not always feasible when annular calcifications prevent proper suture placement or when an abscess involves the mitral annulus. This report describes a surgical technique practiced in our clinic (Department of Cardiothoracic Surgery, University Hospital, Otto-von-Guericke-University, Magdeburg, Germany) that can be used in such high-risk patients to avoid left ventricular rupture.

Rapidly vanishing left atrial dissection following mitral valve replacement: a case report

BackgroundLeft atrial dissection is an extremely rare complication of mitral valve replacement. Because of its severity, its prompt diagnosis and treatment is mandatory. The most effective treatment (i.e. surgical vs. non-surgical) for left atrial dissection has not been fully established yet.Case presentationHerein, we have reported left atrial dissection after mitral valve replacement in a 68-year-old obese woman. After closing the thorax, transesophageal echocardiography (TEE) revealed an atrial mass of 3 cm × 2 cm, visualized as an oval hypoechoic appearance extending from the posterior annulus of the mitral valve to the posterior wall of the left atrium. Because hemodynamic conditions were stable, surgery was ruled out and conservative treatment with close observation was selected. On postoperative day 2, TEE revealed that the atrial mass had vanished and the broken piece of the endocardium merely remained fluttering in the atrium. On postoperative day 6, the appearance of the left atrium was normalized completely, leaving no traces of left atrial dissection. The patient recovered uneventfully. Serial TEE was a very effective imaging modality during the non-surgical treatment of left atrial dissection.ConclusionsIt is crucial to accurately define diagnosis and optimally consider therapeutic strategies for left atrial dissection based on the hemodynamic conditions of the patient and serial TEE follow-up examinations. In our case study, left atrial dissection was successfully treated with conservative treatment; therefore, we believe that TEE could be a feasible modality for the early diagnosis of this condition.

Spontaneous rupture of left ventricular posterior wall as a complication of mitral valve replacement

In this article, we provided summary of knowledge on left ventricular posterior wall rupture as a complication of mitral valve replacement surgery and shared our experience with such complication.

MITRACLIP: ALTERNATIVE TREATMENT FOR HEMOLYTIC ANEMIA INDUCED BY MITRAL PARA-ANNULOPLASTY RING LEAK

Hemolytic anemia is a rare complications of mitral valve replacement or repair due to regurgitation around the prosthesis or annuloplasty ring. Percutaneous transcatheter techniques have been previously applied to the treatment of paraprosthetic valve leak. We report a case using MitraClip to treat

Early experience of percutaneous paravalvular leak closure using a novel Occlutech occluder.

Paravalvular regurgitation is an important complication of mitral valve replacement. Although surgical repair is mostly recommended, it is associated with significant morbidity. On the other hand, percutaneous closure is a less invasive alternative approach. Percutaneous approaches to treatment of paravalvular prosthetic regurgitation have emerged recently. One of them is the Occlutech Paravalvular Leak Device. The aim of this study was to evaluate early and midterm outcomes of percutaneous paravalvular leak closure utilising a novel occluder. Twenty-one consecutive symptomatic patients who had moderate or severe paravalvular prosthetic regurgitation on transoesophageal echocardiography were included in the study. All the patients were clinically evaluated and found inoperable for surgery. They underwent transapical repair with the Occlutech Paravalvular Leak Device. The patients were followed for 17±5 months. Attempts were made to rectify 41 defects in 21 patients with 100% success. Mean procedure time was 76±40 min and fluoro-scopy time was 44±37 min. Early post-procedural outcome was uneventful in all cases, with ≥1 grade reduction in regurgitation in all of the patients. There was no mortality during hospital stay. There was one case of haemothorax in one patient and one case of pneumothorax in another. Post-implantation 90-day follow-up data were obtained for 19 patients, and 12-month data were obtained for 12 patients. No deaths due to any cause, stroke or surgery for prosthetic impingement, worsening or relapse of paravalvular leak during follow-up were recorded. One patient underwent reintervention and was treated successfully with the same occluder 11 months after the index procedure. The novel Occlutech Paravalvular Leak Device, which was designed specifically for mitral and aortic paravalvular regurgitation, is an additional, useful tool in the device armamentarium for the treatment of PVL.

Phasic disappearance of left circumflex coronary artery from an early complication of mitral valve surgery.

Key Clinical MessageLV pseudoaneurysm can be a late complication of mitral valve replacement. In our case, it was an early postoperative complication. This pseudoaneurysm was causing compression of LCX artery during systole, leading to presentation of NSTEMI two weeks after the surgery.

Left ventricular rupture following mitral valve replacement secondary to chronic steroid use

Ventricular rupture is a rare but fatal complication of mitral valve replacement. We present two patients who died of left ventricular rupture with chronic steroid use as a common factor. Several precautions were taken despite which we encountered this disastrous complication. We believe that the friable nature of the tissues of patients on long-term steroids may be a predisposing factor for the development of left ventricular rupture.

Off pump repair of left ventricular rupture following mitral valve replacement: The crucial assistance of the IntraAortic Balloon Pump

INTRODUCTIONLeft ventricular (LV) rupture is a not as frequent, but potentially lethal complication of mitral valve replacement or repair. PRESENTATION OF CASEWe report a case of a 67-year-old man who underwent mitral valve replacement and Cox Maze IV procedure. A massive bleed from the LV rupture was noted postoperatively while the patient was extubated. The control of bleeding was impossible until an IntraAortic Balloon Pump (IABP) was inserted. A bovine pericardial patch was applied, overlapping an extensive epicardial area, perimetrically of the hematoma. Between the epicardium and the pericardial patch we applied an autologous fibrin sealant. DISCUSSIONThe off-pump technique used to repair the LV rupture after a MVR, is more feasible when the patient is supported by an IABP that subsequently decreases the tension of the myocardial suture site. CONCLUSIONThe IABP, is a necessary device, that decreases the tension along the suture site post a left ventricular rupture following a MVR.

Cases of Hemolytic Anemia with Periprosthetic Leaks Evaluated by Real-Time 3-Dimensional Transesophageal Echocardiography

Hemolytic anemia is recognized as a rare complication of mitral valve replacement or repair. We report on a 44-year-old man with shortness of breath and hemolytic anemia, 23 years after mitral valve replacement (Hall-Kaster), and a 63-year-old woman diagnosed of hemolytic anemia, 4 years after mitral and tricuspid annuloplasty (Tailor ring, An-core ring). Routine 2-dimensional transthoracic echocardiography revealed paravalvular leakage around the prosthesis. Subsequent real-time 3-dimensional (3D)transesophageal echocardiography helped the perceptional appreciation of the leakage and the measuring of the regurgitant orifice area using the anatomically correct plane. Surgical findings of each case fit those of 3D volumetric images.

Modified Cabrol Shunt to Treat Left Ventricular Rupture

Left ventricular rupture is a rare but potentially fatal complication of mitral valve replacement. We describe how a modified Cabrol shunt was used to address intractable hemorrhage from a left ventricular rupture after reoperative mitral valve replacement.

Three-dimensional echocardiography-guided repair of severe paravalvular regurgitation in a bioprosthetic and mechanical mitral valve

Severe paravalvular mitral regurgitation is a rare but important complication of mitral valve replacement, often producing symptoms associated with refractory heart failure or haemolysis. Explantation and replacement of the prosthesis are required in some patients but may not be possible in patients with high risk of morbidity or mortality with re-operation. We present two patients with symptomatic paravalvular mitral regurgitation who were deemed too high risk for re-operation because of multiple previous sternotomies and comorbidities. Percutaneous three-dimensional (3D) echocardiography-guided repair with septal occluder devices was undertaken in the first case of a paravalvular defect adjacent to a mitral bioprosthesis and in the second case adjacent to a mechanical mitral prosthesis. Both cases illustrate the advantage 3D echocardiography provides by allowing en-face views of the paravalvular leak and unique views of the catheter and device placement. The second case further demonstrates the novel use of full volume colour to define the extent of the regurgitant jet and provides information critical to device sizing and placement.

A Serious Complication Late After Mitral Valve Replacement: Left Ventricular Rupture with Pseudoaneurysm

We report a left ventricular pseudoaneurysm, an unusual complication of mitral valve replacement (MVR) in a 65-year-old man who had undergone coronary artery bypass grafting and MVR surgery two years ago. The patient was referred to our clinics because of progressive exertional dyspnea and palpitations. Transthoracic and transesophageal echocardiography showed a large pseudoaneurysm of the posterolateral left ventricular wall and computerized tomographic angiography (CTA) demonstrated the location and the size of the pseudoaneurysm and its neck. Urgent surgical repair was accomplished without complications.

Fibrin Sealant for Left Ventricular Rupture after Mitral Valve Replacement

Despite safer surgical procedures, left ventricular rupture remains a rare but potentially lethal complication of mitral valve replacement. The use of fibrin sealant has substantially improved the outcome of many difficult bleeding episodes after cardiac surgery. We describe a case of left ventricular rupture successfully treated with fibrin sealant combined with external Teflon-pledgeted sutures.

Hybrid repair of mitral paravalvular leak: Open surgical placement of a percutaneous occluder device

Paravalvular leak (PVL) is a rare but serious complication of mitral valve replacement. 1,2 Although PVLs have traditionally been repaired surgically, there has been a growing interest in the attempt to close PVLs through the use of percutaneous interventional techniques with occluder devices. Herein we report an innovative and multidisciplinary approach to the repair of a severe mitral PVL in a patient with aortic and mitral mechanical prostheses. Interventional techniques were not successful, and the intraoperative exposure of the anterolateral mitral PVL was extremely difficult because of the presence of the aortic prosthesis. To our knowledge, this is the first reported case of an open surgical placement of a percutaneous occluder device to repair a mitral paraprosthetic leak.

Giant Left Ventricular Pseudoaneurysm After Mitral Valve Replacement and Myocardial Infarction

Left ventricular pseudoaneurysm is a rare but serious complication of mitral valve replacement or myocardial infarction. Prompt surgical correction is mandatory in cases of a large left ventricular pseudoaneurysm. A 70-year-old man had a giant left ventricular pseudoaneurysm after myocardial infarction and mitral valve replacement. The orifice of the pseudoaneurysm was closed with an e-polytetrafluoroethylene patch and the pseudoaneurysmal wall was almost resected.

Endoventricular pocket repair of type I myocardial rupture after mitral valve replacement: a new technique using pericardial patch, Teflon felt, and BioGlue

Left ventricular (LV) rupture is an infrequent but potentially lethal complication of mitral valve replacement and repair. We report the case of an 82-year-old man who underwent mitral valve replacement and the repair of an atrial septal defect. Both valve leaflets were excised and the annulus was extensively decalcified, followed by the implantation of a bioprosthetic valve. LV rupture was diagnosed after weaning from cardiopulmonary bypass (CPB). CPB was resumed and the bioprosthetic valve was removed. The patient then underwent a unique repair using a pericardial patch, Teflon felt (Meadox Medical Inc, Oakland, NJ), and BioGlue (CryoLife Inc, Kennesaw, GA). A second valve was implanted with a successful outcome.

Valeur pronostique des fuites paraprothétiques aseptiques après remplacement valvulaire mitral par une prothèse Saint Jude Médical (SJM)

Periprosthetic regurgitation (PPR) is a common complication of mitral valve replacement (MVR). The management of moderate and minor PPR remains controversial. The goal of this prospective study was to determine the incidence, predictors and outcome of PPR discovered using omniplan transœsophageal echocardiography (TEE) performed at the early postoperative period (14.7 days) of MVR with SJM prosthesis. Our study enrolled 56 patients, the mean age was 44.5 ±11.9 years. The incidence of PPR was 59% (33 patients). TEE showed one jet in nine patients (27%), two jets in 23 patients (70%) and three jets in one patient (3%). PPR is minor in 24 patients (63%) and moderate in nine patients (27%). No patient developed hemolytic anemia or congestive heart failure. In univariate analysis, diameter of prostheses >27 mm, number of suture knots <17 and diameter of prostheses/number of knot ratio >1.7 independently predicted the presence of PPR. In multivariate analysis only a rapport diameter of protheses/number of suture knots >1.7 mm is predictif of PPR (odd ratio =9, P =0.036). Ninety percent of PPR remained present at six weeks and only 29% were present after 12.5 months. Conclusion: mild and minor PPR were frequent during the early postoperative period after MVR. The clinical significance and natural history is benign and they do not require any specific treatment.