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Ann Thorac Surg 1999;68:1394-1396
© 1999 The Society of Thoracic Surgeons

Case Reports

Treatment of left atrial dissection after mitral repair: internal drainage

Michele Genoni, MDa, Rolf Jenni, MDb, Edith R. Schmid, MDc, Paul R. Vogt, MDa, Marko I. Turina, MDa

a Clinic for Cardiac Surgery, Zurich, Switzerland
b Division of Echocardiography, Zurich, Switzerland
c Division of Cardiovascular Anesthesia, University Hospital Zurich, Zurich, Switzerland

Adress reprint requests to Dr Genoni, Clinic for Cardiac Surgery, University Hospital, CH-8091 Zurich, Switzerland


   Abstract
Top
 Abstract
Introduction
 References
 
Two patients with intraoperative dissection of the entire left atrium after mitral valve repair are presented. Intraoperative transesophageal echocardiography detected left atrial dissection with formation of a large cavity compressing the left atrium. The false lumen was opened and widely connected to the right atrium to perform the decompression. This technique permits the runoff into the low pressure system in case of persisting hemorrhage from the unknown entry, and eliminates the risk of systemic embolization from the cavity.


   Introduction
Top
 Abstract
 Introduction
References
 
Left atrial dissection after mitral valve procedure is a rare but serious complication. Review of the literature reveals only few cases, which occurred after repetitive mitral valve replacement, debridement of extensive calcification of the mitral annulus, and external cardiac massage [1–3].

Cardiac ruptures have been described in 1.3% of patients undergoing mitral valve replacement [4]. Atrial dissection is a variation of a type I ventricular rupture localized at the posterior atrioventricular groove [5]. Elderly women with a heavily calcified annulus and small ventricles are at particularly high risk [4]. Ruptures are considered to be due to technical maneuvers during the operation (air removal from the apex), stretch injuries provoked by the untethering of the left ventricle through removal of the mural leaflet of the mitral valve, or to the resection of papillary muscles.

Two patients presented with intraoperative dissection of the entire left atrium after mitral valve reconstruction. Both patients, a 63-year-old woman (patient A) and a 50-year-old man (patient B), underwent mitral valve repair for mitral regurgitation due to a prolapse of the anterior leaflet. Cardiopulmonary bypass was performed using moderate hypothermia and cardioplegic arrest. Mitral valve was repaired by transferring the posterior chordae to the anterior leaflet. The prolapsed portion of the anterior leaflet was replaced by a quadrangular part of the posterior leaflet and its attached chorda. Subsequently, the posteromedial commissure was readjusted using an annuloplasty. The posterior leaflet was reattached, and the circumference of the posterior annulus was reduced applying a horizontal mattress suture through the annulus.

After successful weaning from cardiopulmonary bypass, routine intraoperative transesophageal echocardiography demonstrated a competent mitral valve and a different appearance of a dissection of the left atrium. In patient A Doppler echocardiography showed a flow originating from the left ventricular cavity to the left atrial wall. The entry of the suggested left atrial dissection is illustrated in Figure 1. In the other patient, a tumor, 5 by 4 cm, was detected occluding the left atrium either from inside or closely behind the free wall of the left atrium. As a hiatal hernia was ruled out using gastroscopy, cardiopulmonary bypass was reestablished supposing a left atrial thrombus.



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  		Fig 1. Dissection of the left atrium. Intraoperative transesophageal echocardiography in patient A: (A) horizontal view; (B) 73-degree view.

 
The surgical treatment of the left atrial dissection was the same in both patients. After incision of the left atrium, its cavity appeared small, compromised by a protrusion of the posterolateral wall. The endocardium was not affected. The dissection cavity was opened, and blood clots were evacuated. The false lumen was irrigated and connected to the right atrium to provide internal drainage and to decompress the cavity. Extracorporeal circulation was successfully terminated.

The postoperative echocardiography demonstrated bidirectional flow through the artificial connection between the dissected left atrial wall and the right atrium (Fig 2). The mitral valve was competent. At discharge and at follow-up after 10 and 12 months, respectively, the patients were assessed as being New York Heart Association functional class I. Echocardiography at follow-up showed pendular perfusion between within the false lumen and the right atrium. Mitral regurgitation was found to be minimal. The size of the left atrium had decreased to almost normal size.



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  		Fig 2. Internal drainage of the atrial dissection. Postoperative transesophageal echocardiography: horizontal view (patient B).

 
The crucial injury to the posterior annulus was presumably caused during annuloplasty. Intense traction of sutures in weak tissue can cause bleeding from the atrioventricular groove, which is not directed outward toward the pericardial cavity, but toward the atrium itself, leading to spread of tissue and formation of a cavity. This was subjected to arterial pressure, probably from the left ventricle, but the origin of bleeding being too small or too distant to become visible during inspection of the cavity. Maeda [2] and Goda [3] and their colleagues described the same location of the injury.

In our technique internal drainage was applied to ensure drainage of a dissected left atrial wall into the right atrium. Hereby, the cavity of the left atrium is restored, while preventing systemic embolization and rupture by further increase of intracavitary pressure.

Furthermore, this report highlights the significance of intraoperative transesophageal echocardiography, which allows an immediate diagnosis and prompt correction of the condition.

In conclusion, left atrial dissection after mitral valve procedure is a rare and severe, but treatable complication. Intraoperative transesophageal echocardiography is decisive for diagnosis. Drainage of the dissected cavity into the right atrium provides an effective tool to prevent further complications without compromising the result of mitral valve reconstruction.


   References
Top
 Abstract
 Introduction
 References
 

  1. Sekino Y., Sadahiro M., Tabayshi K. Successful surgical repair of left atrial dissection after mitral valve replacement. Ann Thorac Surg 1996;61:1528-1530.[Abstract/Free Full Text]
  2. 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;39:382-384.[Abstract]
  3. Goda T., Ishii K., Shiiya N., Oba J., Matsui Y., Yasuda K. Acute dissection of the interatrial septum after re-replacement of mitral valve. J Jpn Assoc Thorac Surg 1994;42:1092-1095.
  4. Karlson K., Ashraf M.M., Berger R.I. Rupture of left ventricle following mitral valve replacement. Ann Thorac Surg 1988;46:590-597.[Abstract]
  5. Treasure R.L., Rainer W.G., Streavey T.E., Sadler T.R. Intra-operative left ventricular rupture associated with mitral valve replacement. Chest 1974;66:511-514.[Abstract/Free Full Text]
Accepted for publication March 8, 1999.




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This Article
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