Ann Thorac Surg 1997;64:684-689
© 1997 The Society of Thoracic Surgeons
Original Article: Cardiovascular
Echocardiographic Recognition of Iatrogenic Aortic Valve Leaflet Perforation
Arthur C. Hill, MD,
Ramesh C. Bansal, MD,
Anees J. Razzouk, MD,
Meizhen Liu, MD,
Leonard L. Bailey, MD,
Steven R. Gundry, MD
Section of Cardiothoracic Surgery, Department of Surgery, and the Section of Cardiology, Department of Medicine, Loma Linda University, Loma Linda, California
Accepted for publication March 10, 1997.
 |
Abstract
|
|---|
Background. There is a paucity of literature regarding iatrogenic aortic valve perforation after cardiac operations performed in the vicinity of the aortic valve. This report describes the echocardiographic recognition of iatrogenic aortic valve perforation.
Methods. Among 6 patients who had previously undergone non–aortic valve cardiac operations, a diagnosis of iatrogenic aortic regurgitation was made by transthoracic two-dimensional echocardiography and Doppler color flow imaging.
Results. The location of the aortic valve leaflet perforation varied and depended on the site of the previous intracardiac lesion repair. Repeat operations in 5 patients confirmed the echocardiographic findings. Aortic valve repair was confirmed in 2 patients by transesophageal echocardiography, whereas aortic valve replacement became necessary in 2 other patients. A fifth patient with acquired cardiomyopathy underwent orthotopic heart transplantation.
Conclusions. A detailed two-dimensional echocardiographic examination, along with color flow imaging, should be done to evaluate iatrogenic aortic valve perforation in patients with a new murmur of aortic regurgitation after cardiac operations in proximity to the aortic valve. Precise preoperative diagnosis of this lesion allows optimal surgical planning and treatment.
|
Introduction
|
|---|
Aortic regurgitation caused by a leaflet perforation is seen most frequently in association with infective endocarditis involving the aortic valve [1, 2]. Iatrogenic aortic valve injury and leaflet perforation have been reported after cardiac operations performed with the transaortic approach, such as repair of a bicuspid aortic valve [3], aortic valve decalcification procedure [4], and septal myotomy-myectomy [5]. Rarely, suture-related, inadvertent injury to an aortic valve leaflet can produce leaflet perforation with regurgitation after cardiac operations performed in the vicinity of the aortic valve (eg, mitral valve replacement, repair of a membranous ventricular septal defect [6], and repair of an ostium primum atrial septal defect [7]). There is a paucity of information on this latter form of iatrogenic aortic valve perforation. This report describes the echocardiographic findings in 6 patients with iatrogenic aortic leaflet perforation and correlation with the proximity of the original surgical repair site to the aortic valve. An increase in the awareness of this entity may help prevent such injuries and will improve its recognition using Doppler echocardiographic techniques.
|
Material and Methods
|
|---|
Patient Selection
Six patients seen in the echocardiography laboratory between 1992 and 1995 with the diagnosis of iatrogenic aortic leaflet perforation and with a history of periaortic cardiac operation formed the basis of this report. Patients presented for evaluation of congestive heart failure with or without a new aortic valve regurgitant murmur after previous cardiac operations in a variety of regional centers. None of these patients had a history of endocarditis or chest trauma. Five of the 6 had operative confirmation. Additionally, we reviewed the charts of 106 patients who had undergone aortic valve operations between 1982 and 1995 for pure aortic regurgitation, and no additional cases of iatrogenic aortic valve perforation were identified.
Echocardiography
Comprehensive transthoracic two-dimensional echocardiographic and color flow Doppler studies were performed on each patient using a variety of commercially available ultrasound equipment [8]. The aortic valve was imaged from the parasternal long-axis, parasternal short-axis, and apical positions. The diagnosis of aortic valve leaflet perforation was made by knowledge of the previous periaortic procedure and the presence of typical echocardiographic findings. Doppler findings included echo-dropout in the body of the aortic valve cusp with or without the presence of an eccentric jet of aortic regurgitant flow in the body of the aortic valve cusp close to the aortic root. Parasternal long- and short-axis echocardiographic views were used to register these findings. The short-axis view confirmed that flow originated from perforation in the body of the cusp and differentiated this from other central and commissural jets of aortic regurgitation.
Operation
At the time of operation, the aortic valve leaflets were inspected and the cause of regurgitation was assessed. All of the operations for iatrogenic aortic valve regurgitation required standard cardiopulmonary bypass through a median sternotomy. Aortic valve repair or replacement was done through a standard aortotomy incision. Aortic valve repair was considered or attempted in every case. The aortic valve was repaired using suture approximation of the edges of the perforated leaflet tissue on 1 patient. Leaflet perforation was repaired in another patient using a pericardial patch. In 2 patients, aortic valve replacement was performed. One patient with complex congenital heart disease required orthotopic heart transplantation.
|
Results
|
|---|
The clinical, echocardiographic, and operative data for all 6 patients are provided in Table 1
. The mean age of the patients was 36 years (range, 8 months to 71 years). There were 2 male and 4 female patients. The original operations done for nonaortic cardiac lesions are also listed in Table 1. This list includes the anatomic sites of the aortic leaflet perforations and the intervals between the original operation and the presentation for repair of iatrogenic aortic regurgitation. The mean interval between the original intracardiac operation and the second procedure for repair of aortic regurgitation was 7 years (range, 0 to 24 years). In 1 patient, the aortic leaflet injury was recognized by intraoperative transesophageal echocardiography at the time of his original operation and required immediate aortic valve replacement.
The sites of the aortic valve leaflet perforations varied and depended on the location of the previous nonaortic intracardiac repair site. One patient who had previously undergone patch repair of an ostium primum atrial septal defect had mild aortic regurgitation because of a small perforation in the noncoronary cusp of the aortic valve (Fig 1). This patient underwent mitral valve replacement because of a cleft-related severe mitral regurgitation, and suture repair of the aortic valve perforation was also performed at that time. Another patient had undergone suture repair of a membranous ventricular septal defect and presented 24 years later with congestive heart failure due to severe aortic regurgitation caused by a large perforation in the right coronary cusp of the aortic valve (Fig 2). The third patient presented with a large perforation in the noncoronary cusp of the aortic valve (Fig 3) after repair of a ventricular septal defect in the setting of a corrected transposition and anterior aorta. The remaining 3 patients had undergone replacement of their mitral valves. Echocardiography in 2 of these patients showed perforations in the noncoronary cusp of the aortic valve (Fig 4). Another patient (patient 6) had perforation of the left coronary cusp of the aortic valve after previous mitral valve replacement. One patient (patient 4) underwent successful repair of the noncoronary cusp perforation using a pericardial patch, and intraoperative transesophageal echocardiography showed intact repair and no residual aortic regurgitation (Fig 5).
View larger version (56K):
[in this window]
[in a new window]
|
Fig 1.. Parasternal short-axis view and its schematic drawing with color flow imaging from patient 1, showing perforation of the noncoronary cusp (N) of the aortic valve and aortic regurgitation (AR) after patch repair of an ostium primum atrial septal defect. ( AO = aorta; IAS = interatrial septal patch; L = left coronary cusp; LA = **left atrium; MPA = main pulmonary artery; PV = pulmonary valve; R = right coronary cusp; RA = right atrium; RVOT = right ventricular outflow tract; TV = tricuspid valve.)
|
|
View larger version (45K):
[in this window]
[in a new window]
|
Fig 2. . Parasternal long-axis view and its schematic drawing along with color flow imaging from patient 2, showing severe aortic regurgitation ( AR) related to a large perforation in the right coronary cusp. This patient had previously undergone suture repair of a membranous ventricular septal defect. ( DA = descending aorta; LA = left atrium; LV = left ventricle; RV = right ventricle.)
|
|
View larger version (115K):
[in this window]
[in a new window]
|
Fig 3. . Pathology specimen of the explanted heart at the time of cardiac transplantation in patient 3 showing the anatomy of the corrected transposition, with a ventricular septal defect ( VSD) and a large perforation ( arrow) in the noncoronary cusp ( NCC) of the aortic valve. The ventricular septal defect is seen through the open pulmonary valve ( PV).
|
|
View larger version (106K):
[in this window]
[in a new window]
|
Fig 4. . Parasternal long-axis views and their schematic drawings without ( left) and with ( right) color flow imaging, showing a large perforation ( arrow) in the noncoronary cusp ( NCC) of the aortic valve after mitral valve replacement with a Medtronic-Hall prosthesis (patient 4). ( AR = aortic regurgitation; AV = aortic valve; DA = descending aorta; LA = left atrium; LV = left ventricle; MV = mitral valve; RCC = right coronary cusp; RV = right ventricle.)
|
|
View larger version (46K):
[in this window]
[in a new window]
|
Fig 5. . Transesophageal echocardiographic longitudinal plain view of the aortic valve and its schematic drawing from patient 4 after repair of the perforation in the noncoronary cusp ( NCC) using autologous pericardium ( arrow). This image was obtained by intraoperative transesophageal echocardiography. ( AO = aorta; LA = left atrium; LV = left ventricle; PMV = prosthetic mitral valve; RPA = right pulmonary artery; RV = right ventricle.)
|
|
|
Comment
|
|---|
Mechanism of Iatrogenic Aortic Valve Perforation
Iatrogenic aortic valve injury that occurs after operations through the transaortic approach in patients with bicuspid aortic valve [3], ultrasonic aortic valve decalcification [4], and hypertrophic obstructive cardiomyopathy [5] is well described in the literature. This report describes a lesser-known entity of iatrogenic aortic valve perforation, which was found in 6 patients after a variety of nonaortic cardiac operations. The proximity of the components of the aortic valve to the adjacent structures (Fig 6) can lead to a site-specific injury of the aortic valve. This injury occurs rarely and is predictable and preventable on the basis of this anatomic specificity. Iatrogenic aortic valve injury can occur at specific aortic valve locations depending on the proximity of the aortic valve to other adjacent cardiac components (see Fig 6). Iatrogenic aortic valve injury is most often a leaflet tear or perforation and can occur at any of the three aortic valve leaflets depending on the type of procedure performed. Possible aortic valve injuries, grouped according to aortic leaflet site (see Fig 6), include:
View larger version (117K):
[in this window]
[in a new window]
|
Fig 6. . A heart at autopsy viewed from the top with the aorta, pulmonary artery, and atria cut away, demonstrating the proximity of the aortic valve cusps to the surrounding structures. Position 1 indicates the proximity of the mitral valve to the noncoronary cusp of the aortic valve and the potential for injury to this cusp during mitral valve surgery. Position 2 indicates the proximity of the membranous septum to the right coronary cusp and the potential for perforation during repair of the defect. Position 3 shows the proximity of the atrial septum and tricuspid valve to the noncoronary aortic cusp and the potential for iatrogenic injury. ( L = left coronary cusp; MV = mitral valve; N = noncoronary cusp; PV = pulmonary valve; R = right coronary cusp; TV = tricuspid valve.)
|
|
- Noncoronary cusp injury during mitral valve repair or replacement through the left atrium; noncoronary cusp injury during repair of ostium primum atrial septal defect through the right atrium; noncoronary cusp injury during repair or replacement of the tricuspid valve through the right atrium (not seen in this series).
- Right coronary cusp injury during repair of membranous ventricular septal defect through the right atrium; right coronary cusp injury during repair of supracristal ventricular septal defect through a pulmonary arteriotomy.
- Left coronary cusp injury during mitral valve repair or replacement through the left atrium.
The aortic valve is not accessible for direct examination during these operations. The usual cause of aortic leaflet injury is placement of a suture through a leaflet, with laceration of the leaflet as the suture is tied, or laceration of the leaflet by a needle as sutures are placed near the aortic annulus. Occasionally, the complication is recognized at the original operation and can be treated at that time (patient 5). In the majority of patients, however, the iatrogenic aortic injury may present several years later with progressive aortic regurgitation. The benefit of increased awareness of this condition is threefold: (1) improved avoidance of this complication while performing cardiac operations in the vicinity of the aortic valve, (2) improvement in the diagnostic yield using echocardiographic techniques, and (3) the ability to plan for operative repair of the iatrogenic leaflet perforation.
Echocardiography
Iatrogenic aortic valve cusp perforation should be suspected when a new aortic regurgitation murmur develops after cardiac operations on the periaortic structures. Parasternal long- and short-axis views with color flow imaging are used for precise diagnosis (see Figs 1, 2, and 4
). The site of the aortic valve cusp involved is related to the location of the previous periaortic operation. The right aortic valve cusp is involved in the repair of membranous ventricular septal defect, the noncoronary cusp in patients with repair of ostium primum atrial septal defect, and the noncoronary cusp and, rarely, the left cusp in patients after mitral valve procedures. Aortic valve repair should be done using intraoperative transesophageal or epicardial echocardiography and consists of primary suture reapproximation of the edges of the leaflet defect or patch repair of the defect using autologous pericardium. Commissuroplasty may be required to reinforce coaptation of the leaflet edges. Certainly, this is a complication that is acknowledged by cardiac surgeons anecdotally although it is rarely reported in the literature [6, 7]. This complication appears to be rare, but is probably under-reported. We also suspect that there is a small fraction of patients who have mild aortic regurgitation due to iatrogenic leaflet perforation who do not present for evaluation or need therapy.
|
Footnotes
|
|---|
Address reprint requests to Dr Bansal, Section of Cardiology, Loma Linda University Medical Center, 11234 Anderson St, Rm 4420, Loma Linda, CA 92354.
|
References
|
|---|
- Fowler NO, Hamburger MH, Bove KE. Aortic valve perforation. Am J Med 1967;42:539–46.[Medline]
- Ballal RS, Mahan EF III, Nanda NC. Aortic and mitral valve perforation: diagnosis by transesophageal echocardiography and Doppler color flow imaging. Am Heart J 1991;121:214–7.[Medline]
- Morganroth J, Perloff JK, Zeldis SM, Dunkman WB. Acute severe aortic regurgitation. Pathophysiology, clinical recognition and management. Ann Intern Med 1977;87:223–32.[Abstract/Free Full Text]
- Freeman WK, Schaff HV, Orszulak TA, Tajik AJ. Ultrasonic aortic valve decalcification: serial Doppler echocardiographic follow-up. J Am Coll Cardiol 1990;16:623–30.[Abstract]
- Mohr R, Schaff HV, Puga FJ, Danielson GK. Results of operation for hypertrophic obstructive cardiomyopathy in children and adults less than 40 years of age. Circulation 1989;80(Suppl 1):191–6.
- Wada J, Yokoyama M, Imai Y, Momma K, Takao A. Hemolysis due to aortic insufficiency following closure of ventricular septal defect. Int Surg 1979;64:53–6.
- Rey C, Vaksmann G, Brevière GM, Dupuis FC. L'Insuffisance aortique: une complication méconnue de la fermeture chirurgicale de la communication interauriculaire ostium primum. Arch Mal Coeur 1991;84:627–31.
- Bansal RC, Tajik AJ, Seward JB, Offord KP. Feasibility of detailed two-dimensional echocardiographic examination in adults: prospective study of 200 patients. Mayo Clin Proc 1980;55:291–308.[Medline]
This article has been cited by other articles:
|
|
|
|
 
K. E. Glas, J. S. Shanewise, and R. A. Guyton
An Unusual Cause of Left Ventricular Outflow Tract Obstruction After Mitral Valve Repair
Anesth. Analg.,
July 1, 2004;
99(1):
38 - 40.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
N. Hasaniya, S. R. Gundry, A. J. Razzouk, N. Mulla, and L. L. Bailey
Outcome of aortic valve repair in children with congenital aortic valve insufficiency
J. Thorac. Cardiovasc. Surg.,
April 1, 2004;
127(4):
970 - 974.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
A. Rother, B. Smith, D. H. Adams, and C. D. Collard
Transesophageal Echocardiographic Diagnosis of Acute Aortic Valve Insufficiency After Mitral Valve Repair
Anesth. Analg.,
August 1, 2000;
91(2):
499 - 500.
[Full Text]
[PDF]
|
|
|
Top
Abstract
Introduction
