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Ann Thorac Surg 1996;61:1528-1530
© 1996 The Society of Thoracic Surgeons

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Case Report

Successful Surgical Repair of Left Atrial Dissection After Mitral Valve Replacement

Department of Thoracic and Cardiovascular Surgery, Tohoku University School of Medicine, Sendai, Japan

Accepted for publication October 30, 1995.

	Abstract

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A rare case of left atrial dissection after mitral valve replacement is reported. Low output syndrome developed in the immediate postoperative period. Cardiac catheterization showed marked elevation of the pulmonary wedge pressure, and left ventriculography revealed massive paraprosthetic leakage with left atrial dissection. At the reoperation, the dissecting cavity was successfully closed from inside the left atrium under cardiopulmonary bypass. We consider this complication another variation of an atrioventricular discontinuity after mitral valve replacement.

	Introduction

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In 1988, a 65-year-old woman underwent mitral valve replacement and tricuspid annuloplasty for mitral stenosis and tricuspid regurgitation. The operation was performed under cardiopulmonary bypass with moderate hypothermia. The left atrium was approached transseptally. There was a large amount of thrombus in the left atrium, which was removed completely. The mitral valve was heavily calcified, and the subvalvular structures were fused. Pathogenesis of this lesion was judged as rheumatic changes. The anterior mitral leaflet was resected. The posterior leaflet and its subvalvular complex were left intact. A 27-mm Björk-Shiley mitral prosthesis (Shiley, Irvine, CA) was implanted using everting mattress sutures of 2-0 Ethibond (Ethicon, Somerville, NJ) with pledgets. After 30 minutes of circulatory assist, the patient was weaned easily from cardiopulmonary bypass.

Low output syndrome developed in the immediate postoperative period. Although a systolic murmur was noticed at apex on the first postoperative day, paraprosthetic leakage could not be detected by repeated transthoracic echocardiogram. As the patient's condition worsened progressively, cardiac catheterization was performed on the 15th postoperative day. The pulmonary wedge pressure was markedly elevated. On left ventriculography, the contrast medium regurgitated first into a small space close to the mitral prosthesis, then into the left atrial cavity, and the whole left atrium became densely opacified. Although pathogenetic details of the complication could not be diagnosed, findings obtained so far suggested the presence of paraprosthetic leakage.

Reoperation was performed on the following day under cardiopulmonary bypass. The left atrium was enlarged, and a thrill was palpable on its surface. When the left atrium was entered through the right interatrial groove, an oval intimal tear with irregular margin was found about 3 cm from the mitral annulus (Fig 1). The size of the tear was 12 x 16 mm in diameter. When the intimal tear was widened, it became clear that a large cavity, 42 x 30 mm in diameter, existed beneath the intimal floor, which communicated with the left ventricle through paraprosthetic channel. It seemed that the entry began at the suture site beneath the annulus and dissected into the left atrial wall, forming a cavity, then ruptured into the left atrial cavity (Fig 2A). There was no disruption of sutures or malfunction of the prosthesis. The dissected cavity and the intimal tear were closed by six mattress sutures with Teflon pledgets from inside the left atrium. The paraannular orifice was closed by four mattress sutures with pledgets, and the prosthetic valve again was fixed (Fig 2B). We took care not to injure the coronary vessels in the atrioventricular groove. The patient's subsequent clinical course was uneventful.

View larger version (33K): [in this window] [in a new window]   Fig 1. . Schematic presentation of the opened left atrium. An intimal tear was seen near the mitral prosthesis, and a dissecting cavity was found to communicate with the left ventricle (LV). (LA = left atrium.)

View larger version (28K): [in this window] [in a new window]   Fig 2. . Schematic presentation of left atrial dissection (A) and its surgical repair (B). (A) The arrow indicates the path of regurgitation, and the stippled area indicates heavy calcification. (B) The repair involved reattaching the prosthetic valve sewing ring and leaflet elements to the still-intact atrial ventricular junction. (CA = coronary artery; CS = coronary sinus; LA = left atrium; LV = left ventricle.)

	Comment

Top Footnotes Abstract Introduction Comment References

Maeda and colleagues [3] have described much the same lesion as reported here. Unlike our case, their patient did not decompensate until the fourth month postoperatively. They thought that the lesion was due to an injury to the posterior annulus that occurred when the mitral prosthesis was excised. Goda and colleagues [4] have reported a case of dissection of the interatrial septum, probably due to excessive debridement of the annular tissue.

Although in our case the posterior leaflet and its subvalvular complex were left intact, a complication ensued. Judging from the reoperative findings, excessive traction on sutures in the posterior annulus at the first operation could have resulted in tearing through the tissues and disruption [2]. Inadvertent injury to the endocardium of the left atrium during the time of left atrial thrombectomy also could have added to the complication.

The diagnosis in this case was delayed for a long time. Because transthoracic echocardiograms could not demonstrate the lesion, we had to resort to catheterization. To our regret, in Japan, transesophageal echocardiography was not in common use in the 1980s. If transesophageal echocardiography had been performed, the patient probably would have been diagnosed and reoperated on earlier. Today, transesophageal echocardiography should be the first choice for diagnosis in this particular case.

Although this complication is a paraprosthetic leakage from a hemodynamic point of view, it may represent another variation of atrioventricular discontinuity after mitral valve replacement in a patient with severe degenerative annular disease with calcification [6], or another form of type I left ventricular rupture.

	Footnotes

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Address reprint requests to Dr Sekino, Department of Cardiovascular Surgery, Saka General Hospital, 16-5 Nishiki-cho, Shiogama 985, Japan.

	References

Top Footnotes Abstract Introduction Comment References

 

1. Treasure RL, Rainer WG, Strevey TE, Sadler TR. Intraoperative left ventricular rupture associated with mitral valve replacement. Chest 1974;66:511–4.[Abstract/Free Full Text]
2. Karlson KJ, Ashraf MM, Berger RL. Rupture of left ventricle following mitral valve replacement. Ann Thorac Surg 1988;46:590–7.
3. Maeda K, Yamashita C, Shida T, Okada M, Nakamura K. Successful surgical treatment of dissecting left atrial aneurysm after mitral valve replacement. Ann Thorac Surg 1985;39:382–4.[Abstract]
4. Goda T, Ishii K, Shiiya N, Oba J, Matsui Y, Yasuda K. Acute dissection of the interatrial septum after re-replacement of the mitral valve: a case report. J Jpn Assoc Thorac Surg 1994;42:1092–5.
5. Romfh RF, Paplanus SH. Dissecting aneurysm of left atrium following external cardiac massage. JAMA 1979;241:1151.[Abstract/Free Full Text]
6. Cohn LH. Management of complications related to mitral valve surgery. In: Waldhausen JA, Orringer MB, eds. Complications in cardiothoracic surgery. St. Louis: Mosby-Year Book, 1991:248–57.

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Mitsuaki Sadahiro Koichi Tabayashi Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Sekino, Y. Articles by Tabayashi, K. Search for Related Content PubMed PubMed Citation Articles by Sekino, Y. Articles by Tabayashi, K.