Ann Thorac Surg 1999;67:1487-1489
© 1999 The Society of Thoracic Surgeons
Case Reports
Severe aortic regurgitation immediately after mitral valve annuloplasty
Anique Ducharme, MDa,
Jean-François Courval, MDc,
Annie Dore, MDa,
Yves Leclerc, MDb,
Jean-Claude Tardif, MDa
a Department of Medicine, Montreal Heart Institute, Montreal, Quebec, Canada
b Department of Surgery, Montreal Heart Institute, Montreal, Quebec, Canada
c Department of Anesthesiology, Montreal Heart Institute, Montreal, Quebec, Canada
Accepted for publication October 28, 1998.
Address reprint requests to Dr Tardif, Montreal Heart Institute, 5000 Belanger East, Montreal, PQ, Canada H1T 1C8
e-mail: tardifjc{at}icm.umontreal.ca
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Abstract
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We report a case of severe aortic regurgitation occurring immediately after the insertion of a mitral annuloplasty ring. On transesophageal echocardiography, regurgitation was found to originate from the retracted left coronary cusp. On direct examination, part of the aortic wall was folded, but no suture could be identified. It was reasoned that tension created by the ring caused the retraction. The problem was corrected by releasing three sutures on the ring. Postoperative course was uneventful.
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Introduction
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The advantages of mitral valve repair over valve replacement are well recognized. It is associated with lower operative mortality, improved ventricular function, less frequent need for anticoagulation, and reduced incidence of thromboembolism and endocarditis [1]. However, mitral valve repair is not without complications: 1%–7% of patients will need a reoperation within 2 years for persistent regurgitation, left ventricular outflow tract obstruction, ring dehiscence, recurrent leaflet prolapse, or severe hemolysis [1–3]. The purpose of this report is to describe a complication with a flexible Carpentier ring for mitral valve repair. Severe aortic regurgitation was diagnosed intraoperatively by transesophageal echocardiography (TEE), and it was corrected by releasing a few sutures on the annuloplasty ring.
A 54-year-old man with hypertension, hypercholesterolemia, and diabetes presented with unstable angina. His diabetes was complicated by end-stage renal failure requiring hemodialysis. Coronary angiography and intravascular ultrasound disclosed a left main stem stenosis for which the patient was referred to surgery. Transthoracic echocardiography (TTE) demonstrated moderate to severe mitral regurgitation (2–3/4) and trivial aortic regurgitation.
To accurately determine the mechanism and severity of mitral regurgitation, intraoperative TEE was performed. A 5.0-MHz multiplane transducer was inserted and connected to an ultrasound unit (2500; Hewlett Packard, Andover, MA). TEE revealed moderate to severe mitral regurgitation (3/4) by color Doppler, and there was abolition of the systolic component of pulmonary venous flow. The mitral anulus was dilated but leaflet morphology and motion were normal. Trivial aortic regurgitation was noted but the aortic valve appeared structurally normal and the aortic root was not dilated. Left ventricular function was normal. Left atrium was mildly dilated. Mitral annuloplasty using a flexible Carpentier ring was therefore performed, in addition to coronary artery bypass grafting.
The patient had an apparently uneventful surgery and was weaned from cardiopulmonary bypass. Once loading conditions normalized, the mitral valve repair was evaluated with TEE. The annuloplasty ring was in good position, trivial residual mitral regurgitation was present, and there was no left ventricular outflow tract obstruction. However, color examination revealed severe aortic regurgitation (Fig 1), which was found to originate from the left coronary cusp on a short-axis view (Fig 2A). On two-dimensional imaging, the left coronary leaflet was retracted while the other cusps appeared normal (Fig 2B). The hypothesis was that this aortic valve leaflet had been entrapped by one of the sutures of the annuloplasty ring. Cardiopulmonary bypass was reinitiated. On direct examination, it was readily observed that part of the aortic wall at the level of the leaflets’ insertion was folded; the leaflets themselves appeared normal. Despite close examination, no suture could be identified. It was reasoned that tension created by the mitral annuloplasty ring pulled on adjacent tissue and caused the retraction of the left coronary cusp. The left atrium was therefore reopened, and the problem was corrected by releasing three sutures on the annuloplasty ring. The patient was then successfully weaned from bypass. TEE showed only trivial aortic regurgitation with greatly improved coaptation of the aortic cusps. The mitral annuloplasty ring remained well positioned; there was a trace of mitral regurgitation and a mean diastolic gradient of 3 mm Hg. The postoperative course was thereafter uneventful.
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Fig 1. Long-axis view at 134 degrees, from the mid-esophageal location, with color flow Doppler. The regurgitant jet occupies almost all the left ventricular outflow tract.
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Fig 2. (A) Short-axis view of the aortic valve from a mid-esophageal location (39 degrees). Color flow Doppler shows that the regurgitant jet originates from the left coronary cusp. (B) Mid-esophageal view, 39 degrees without color: short-axis view of the aortic valve. The left coronary cusp appears retracted.
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Comment
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Mitral ring annuloplasty is used to correct dilatation of the annulus, increase leaflet coaptation, reinforce annular suture lines, and prevent further annular dilatation [1–3]. A number of complications have been described with its use. Postoperative valvular incompetence is the most common finding. Despite the absence of insufficiency during the direct infusion of saline [4], some degree of mitral regurgitation has been found in up to 15% of cases (most often, mild) with echocardiography [4]. Reinstitution of cardiopulmonary bypass is required in 8% of patients because of incomplete correction (3%), left ventricular outflow tract (LVOT) obstruction (3%), or suture dehiscence (2%) [5]. The reported incidence of LVOT obstruction has, however, varied from 4% to 21% [1]. Dehiscence of the prosthetic ring, ring fracture, and hemolysis are uncommon complications (<1%) that can be encountered during follow-up [3]. Severe aortic regurgitation represents another infrequent complication of a mitral annuloplasty ring. Overall, the rate of reoperation at 2 years ranges from 1% to 7% [1–3].
Intraoperative TEE provides detailed definition of the mitral valve and subvalvular apparatus. The mechanism and severity of native and prosthetic valve regurgitation can be precisely identified, and results of the surgical intervention assessed. Ventricular function can be monitored with TEE, and this is particularly useful in patients who could be difficult to wean from cardiopulmonary bypass. TEE can also identify unsuspected associated lesions that can be repaired during the same intervention in 3% to 11% of patients [6]. This case report underlines the importance of obtaining a complete intraoperative TEE after valvular repair. Otherwise, the complication could have been diagnosed in the intensive care unit. However, the patient would probably have been exposed to prolonged mechanical ventilation, significant amount of vasopressors, or inotropic agents and may have suffered cardiogenic shock before identification of the proper diagnosis. Providing the surgeon with a rapid and detailed anatomic description gave him the opportunity to immediately correct the abnormality during the same intervention.
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References
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Cosgrove D.M., Stewart W.J. Mitral valvuloplasty. Curr Probl Cardiol 1989;14:359-415.[Medline]
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Carpentier A., Chauvaud S., Fabiani J.N., et al. Reconstructive surgery of mitral valve incompetence. J Thorac Cardiovasc Surg 1990;79:338-348.[Abstract]
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Spencer F.C., Colvin S.B., Culliford A.T., Isom O.W. Experiences with the Carpentier techniques of mitral valve reconstruction in 103 patients (1980–1985) and discussion. J Thorac Cardiovasc Surg 1985;90:341-350.[Abstract]
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King H., Csicsko J., Leshnower A. Intraoperative assessment of the mitral valve following reconstructive procedures. Ann Thorac Surg 1980;29:81-83.[Abstract]
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Marwick T.H., Stewart W.J., Currie P.J., Cosgrove D.M. Mechanisms of failure of mitral valve repair: an echocardiographic study. Am Heart J 1991;122:149-156.[Medline]
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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]
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Abstract
Introduction
