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Ann Thorac Surg 1999;67:1484-1485
© 1999 The Society of Thoracic Surgeons

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Case Reports

Stuck valve leaflet detected by intraoperative transesophageal echocardiography

^a Second Department of Surgery, Osaka City University Medical School, Osaka, Japan
^b Division of Cardiovascular Surgery, Osaka City General Hospital, Osaka, Japan

Accepted for publication October 26, 1998.

Address reprint requests to Dr Kumano, Second Department of Surgery, Osaka City University Medical School, 1-5-7, Asahimachi, Abeno-ku, Osaka 545-0051, Japan

	Abstract

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We encountered a rare complication of mitral valve replacement with the CarboMedics prosthesis: a "stuck" leaflet detected by transesophageal echocardiography even though weaning from cardiopulmonary bypass had been uneventful. The patient was immediately managed without significant problems. We emphasize the importance of performing routine intraoperative transesophageal echocardiography in valve replacement as well as in valve repair, from the initial phase of operation.

	Introduction

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The usefulness of intraoperative assessment of cardiac function with transesophageal echocardiography (TEE) has been established, particularly in valve repair [1, 2]. We report a case of a stuck prosthetic valve leaflet detected by intraoperative TEE despite an uneventful weaning from cardiopulmonary bypass (CPB), which was immediately managed without difficulty.

A 57-year-old man was admitted to our hospital for surgical treatment of mitral regurgitation (MR) due to mitral valve prolapse. Preoperative transthoracic echocardiography revealed prolapse of the posterior leaflet of the mitral valve and MR. Mitral valve repair was attempted at first, but because of residual MR, mitral valve replacement (MVR) was substituted, using a 29-mm CarboMedics prosthesis in the antianatomic position. After completion of the valve replacement, the patient was weaned from CPB under inotropic support without difficulty, and his hemodynamic condition was stable. However, when the prosthesis was assessed using TEE, one of the leaflets of the prosthesis was seen to be stuck in the closed position (Fig 1). CPB was instituted again, cardiac arrest was resumed, and the left atrium was reopened. On inspection of the prosthesis, a leaflet on the side of the anterolateral commissure was stuck in the closed position because of residual tissue in proximity the leaflet. Normal valve function was restored by a 90-degree rotation of the prosthesis (Fig 2), and the operation was completed. The fluoroscopic appearance of the functioning prosthesis 16 days after surgery was good, and the patient was discharged in good condition.

View larger version (122K): [in this window] [in a new window]   Fig 1. Intraoperative transesophageal echocardiogram showing the "stuck" leaflet (arrow) of the CarboMedics prosthesis in the mitral position. (LA = left atrium; LV = left ventricle.)

View larger version (102K): [in this window] [in a new window]   Fig 2. After the second termination of cardiopulmonary bypass, no prosthetic valve dysfunction is evident. Abbreviations are as in Fig 1. (large arrow = closed leaflets; small arrow = open leaflets).

	Comment

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Leaflet sticking due to residual tissue like that detected in the present case is considered rare with bileaflet prostheses including CarboMedics prosthesis [3, 4], and this was the first experience in our institution. Elsewhere, Jaggers and associates [5] described a case of MVR in which one leaflet of a St. Jude Medical mitral prosthesis had become stuck, although the underlying cause of this valve dysfunction was not identified. In their case, weaning from CPB could not be achieved because the patient developed marked pulmonary hypertension. Upon assessment using TEE, they found a stuck leaflet, and operatively corrected the valve dysfunction. Successful management in our case resulted from the use of TEE in the initial phase of operation, permitting assessment of the unexpectedly malfunctioning prosthetic valve immediately after the termination of CPB. Because additional patients may be hemodynamically stable despite prosthetic valve dysfunction undetected by electrocardiogram, arterial pressure, or Swan-Ganz catheter monitoring, intraoperative TEE should be added to other routine assessments in valve replacement operations.

According to Daniel and associates [6], complications associated with TEE occurred in 18 cases (0.18%) of 10,218; bleeding due to insertion occurred in only two, including a case where bleeding was caused by an esophageal tumor. In our institution, TEE monitoring has been used routinely since 1994 in the initial phase of cardiac surgery without complications. Insertion of the TEE probe should precede CPB with its associated systemic heparinization, to avoid bleeding.

In conclusion, we emphasize the importance of performing routine intraoperative TEE in cardiac surgery from the initial phase of operation, for immediate management of unexpected events.

	References

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1. Bryan A.J., Barzilai B., Kouchoukos N.T. Transesophageal echocardiography and adult cardiac operations. Ann Thorac Surg 1995;59:773-779.[Abstract/Free Full Text]
2. Freeman W.K., Schaff H.V., Khandheria B.K., et al. Intraoperative evaluation of mitral valve regurgitation and repair by transesophageal echocardiography: incidence and significance of systolic anterior motion. J Am Coll Cardiol 1992;20:599-609.[Abstract]
3. Fiane A.E., Saatvedt K., Svennevig J.L., Geiran O., Nordstrand K., Frøysaker T. The CarboMedics valve: midterm follow-up with analysis of risk factors. Ann Thorac Surg 1995;60:1053-1058.[Abstract/Free Full Text]
4. Fernandez J., Laub G.W., Adkins M.S., et al. Early and late-phase events after valve replacement with the St. Jude Medical prosthesis in 1200 patients. J Thorac Cardiovasc Surg 1994;107:394-407.[Abstract/Free Full Text]
5. Jaggers J., Chetham P.M., Kinnard T.L., Fullerton D.A. Intraoperative prosthetic valve dysfunction: detection by transesophageal echocardiography. Ann Thorac Surg 1995;59:755-757.[Abstract/Free Full Text]
6. Daniel W.G., Erbel R., Kasper W., et al. Safety of transesophageal echocardiography. A multicenter survey of 10,419 examinations. Circulation 1991;83:817-821.[Abstract/Free Full Text]

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This Article Abstract Full Text (PDF) 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): Shigefumi Suehiro Toshihiko Shibata Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Kumano, H. Articles by Kinoshita, H. Search for Related Content PubMed PubMed Citation Articles by Kumano, H. Articles by Kinoshita, H.