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Ann Thorac Surg 1995;59:755-757
© 1995 The Society of Thoracic Surgeons

Case Reports

Intraoperative Prosthetic Valve Dysfunction: Detection by Transesophageal Echocardiography

James Jaggers, MD, Paul M. Chetham, MD, Theresa L. Kinnard, MD, David A. Fullerton, MD

Departments of Surgery and Anesthesiology, University of Colorado Health Sciences Center, Denver, Colorado

Accepted for publication July 12, 1994.


   Abstract
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We describe the valuable role of intraoperative transesophageal echocardiography in the detection of immediate prosthetic valve dysfunction. Transesophageal echocardiography accurately diagnosed one leaflet of a St. Jude Medical mitral valve to be stuck. We recommend routine transesophageal echocardiography for mitral valve operations.


   Introduction
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Transesophageal echocardiography (TEE) has become a valuable intraoperative tool in cardiac surgery. Its uses include monitoring of cardiac function and intracardiac volume, detection of intracardiac air, and intraoperative assessment of repair of congenital heart defects. It is especially valuable in the assessment of mitral valve repair [1]. Herein we report the valuable role played by intraoperative TEE in the diagnosis of a malfunctioning St. Jude Medical prosthesis placed in the mitral position in 1 patient. The use of TEE proved life-saving.

A 39-year-old man underwent mitral valve replacement for critical mitral stenosis. His preoperative cardiac catheterization demonstrated moderate pulmonary hypertension with a mean pulmonary arterial pressure of 31 mm Hg and a pulmonary vascular resistance of 375 dynes • s • cm-5. Coronary arteriography and left ventricular function were normal. The native mitral valve was badly calcified, so all leaflet material and chordae were resected. The chordae were amputated at their junction with the papillary muscles. A 29-mm St. Jude Medical mitral prosthesis (St. Jude Medical, St. Paul, MN) was placed without difficulty (Fig 1Go). Once the aortic cross-clamp was removed and the patient was rewarmed, the heart demonstrated excellent function on total cardiopulmonary bypass without inotropic support. Weaning from cardiopulmonary bypass therefore was begun. However, each time weaning was attempted, the patient's mean pulmonary arterial pressures increased to more than 45 to 50 mm Hg and he failed to be weaned from bypass despite what appeared to be excellent left ventricular function. Examination of the heart demonstrated no reason for failure to be weaned from cardiopulmonary bypass; therefore, TEE was employed to examine the prosthetic mitral valve.



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  		Fig 1. . Anatomic orientation of the insertion of the St. Jude mitral valve. Arrows indicate location of mitral valve commissures. Both valves were placed in this orientation.

 
It was apparent from TEE that one leaflet of the mitral valve was stuck in the closed position (Fig 2Go). Total cardiopulmonary bypass then was resumed, cardioplegia administered, and the left atrium reopened. On inspection of the valve the most posterior leaflet was indeed stuck shut. However, with a cotton-tipped swab the leaflet was easily ``popped'' open and thereafter its mechanism appeared normal. No tissue impinging upon the mechanism could be identified; therefore, the left atrium was closed and once again an attempt was made to wean the patient from bypass. During this interval the mechanism of the valve was monitored by TEE and both leaflets moved freely. However, just before cessation of cardiopulmonary bypass, under direct observation with TEE, this same leaflet of the St. Jude mitral prosthesis abruptly stuck in the shut position and total cardiopulmonary bypass was resumed. The patient was once again cooled to 28°C, cardioplegia was administered, and the left atrium was opened. The same leaflet of the valve was stuck once again, so the prosthesis was excised. Great care was taken to observe the tissue on the ventricular side of the valve and we are confident that, at least in the state of cardioplegia, no tissue was impinging upon the mechanisms of the mitral prosthesis. A 31-mm St. Jude mitral valve was rapidly reimplanted in the same anatomic position. The patient was weaned from cardiopulmonary bypass, albeit with great difficulty, requiring significant inotropic support. Nonetheless, the patient ultimately made a successful recovery and was discharged from the hospital. One week after discharge the patient was ambulating 4 miles daily and was in New York Heart Association class I.



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  		Fig 2. . Intraoperative transesophageal echocardiogram of St. Jude valve with one leaflet stuck closed. (LA = left atrium; large arrow = stuck leaflet; small arrow = open leaflet.)

 

   Comment
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We believe this case is important for two reasons. First, it is rare for a St. Jude mitral prosthesis to become acutely stuck in the closed position. Large studies have reported long-term follow-up of the St. Jude prosthesis without structural malfunction [2]. Most immediate complications of valve placement result from retained native valve structures interfering with proper valve closure, producing regurgitation. In this case we found no such tissue. The valve involved in this case is currently under evaluation by an independent engineering firm.

Second, this case clearly demonstrates the value of TEE in what would otherwise have been considered a routine operation. We had no reason to suspect a mechanical problem with the mitral prosthesis. Furthermore, it is not uncommon for patients undergoing mitral valve replacement with preexisting pulmonary hypertension from mitral stenosis to experience an acute increase in pulmonary arterial pressure in the immediate perioperative period [3]. Without the assistance of TEE, a potentially lethal error may have been made by attributing this patient's inability to be weaned from cardiopulmonary bypass to such pulmonary hypertension. Transesophageal echocardiography provided for prompt diagnosis and management of prosthetic valve dysfunction. This case illustrates that TEE may play an invaluable role in the intraoperative assessment of mitral valve replacement as well as repair. We recommend its routine use for mitral valve operations.


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Address reprint requests to Dr Fullerton, Cardiothoracic Surgery, C-310, University of Colorado Health Sciences Center, 4200 E 9th Ave, Denver, CO 80262.


   References
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 Introduction
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 References
 

  1. Goldman ME, Mindich BP. Intraoperative two-dimensional echocardiography: new application of an old technique. J Am Coll Cardiol 1986;7:374–82.[Abstract]
  2. Fernandez J, Laub GW, Adkins MS, et al. Early and late-phase events after valve replacement with the St. Jude Medical prosthesis in 1200 patients. J Thoracic Cardiovasc Surg 1994;107:394–407.[Abstract/Free Full Text]
  3. D'Ambra MN, Beller JP. Pulmonary circulation: pharmacologic management. In: Grillo HC, Austen WG, Wilkens EW, Mathisen DJ, Vlahakes GJ, eds. Current therapy in cardiothoracic surgery. Toronto: Decker, 1988:278–82.



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This Article
Right arrow Abstract Freely available
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Right arrow Author home page(s):
James Jaggers
David A. Fullerton
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Right arrow Articles by Jaggers, J.
Right arrow Articles by Fullerton, D. A.

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