Ann Thorac Surg 2001;71:343-345
© 2001 The Society of Thoracic Surgeons
Case report
Left ventricular–right atrial fistula complicating redo mitral valve replacement
Malte Weinrich, MDa,
Thomas P. Graeter, MDa,
Frank Langer, MDa,
Hans-Joachim Schäfers, MD, PhDa
a Department of Thoracic and Cardiovascular Surgery, University Hospitals of Saarland, Homburg/Saar, Germany
Accepted for publication April 7, 2000.
Address reprint requests to Dr Schäfers, Department of Thoracic and Cardiovascular Surgery, University Hospitals, Kirrberger Str, 66421 Homburg/Saar, Germany
e-mail: chhjsc{at}med-rz.uni-sb.de
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Abstract
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We describe the case of a 58-year-old female patient who underwent redo mitral valve replacement and remained in heart failure. The diagnosis of a left ventricular–right atrial fistula was made. The fistula was closed surgically with a patch of autologous pericardium. The patient improved immediately after the operation and has been asymptomatic since.
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Introduction
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Although mitral valve replacement is a routine procedure, it may still result in structural defects with significant hemodynamic compromise. The most frequent is paravalvular leakage due either to torn out sutures or to prosthetic valve endocarditis [1]. A rare complication is the development of a left ventricular–coronary sinus fistula. A left ventricular–right atrial shunt occurs even less frequently. Both lesions result in an intracardiac shunt, and are commonly associated with concomitant heart failure. Surgical closure of these defects appears advisable.
A 58-year-old female patient underwent mitral valve replacement with a 29-mm Bjoerk-Shiley prosthesis for rheumatic mitral valve disease 21 years ago. Redo mitral valve replacement became necessary for thrombosis of the mitral prosthesis secondary to insufficient anticoagulation 4 years before the current presentation. In this second operation the old prosthesis was removed and a 29-mm St. Jude Medical prosthesis (St. Jude Medical, Minneapolis, MN) was implanted. The postoperative course was uneventful except the patient still exhibited signs of heart failure after this operation.
Because of a systolic heart murmur the patient’s primary physician performed transthoracic echocardiography. The findings were interpreted as a mild mitral valveinsuffiency, most likely due to paravalvular leakage. The patient’s congestive heart failure worsened progressively until she reached New York Heart Association functional class III–IV.
The patient was then referred to our institution. A communication between the left ventricle and the right atrium was seen by tranesophageal echocardiography and cardiac catheterization. A left-to-right shunt of approximately 50% was determined and the patient was scheduled for reoperation.
The chest was opened by median sternotomy. After dissection of adhesions, extracorporal circulation was initiated with aortic and bicaval cannulation. The right atrium was opened and a defect of approximately 10 mm in diameter in the atrial septum adjacent to the tricuspid valve was seen (Fig 1). A probe could be passed through this defect directly into the left ventricle. It was decided to close this communication to the left ventricle using a autologous pericardium. Mattress sutures were placed into the ring of the tricuspid valve, the ring of the mitral prosthesis, and into the adjacent atrial septum (Figs 1 and 2). A patch of autologous pericardium was fixed in glutaraldehyde and the defect closed using the sutures already placed. Because of concomitant dilatation of the tricuspid ring its size was normalized using the De Vega technique [2]. The patient was weaned from extracorporal circulation without problem. She was extubated and the postoperative course was uneventful. The patient was discharged on the seventh postoperative day. Postoperative echocardiography revealed normal function of the mitral prosthesis without evidence of paravalvular leakage or intracardiac shunting. Eighteen months postoperatively the patient continues to do well with minimal dyspnea on exertion (New York Heart Association functional class II). Transthoracic echocardiography again documented normal function of the mitral prosthesis and absence of paravalvular leakage or intracardiac shunting.
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Fig 1. View into a right atriotomy showing the direct communication between the left ventricle and the right atrium of approximately 1 cm in diameter. Mattress sutures are placed into the mitral prosthesis annulus, the tricuspid annulus, and the septum.
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Comment
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The development of structural defects is a rare complication after mitral valve replacement. Most commonly paravalvular leakage is observed and its development is largely prosthesis independent [1, 3]. If the careful suture technique is used the incidence of paravalvular leakage approaches zero in uninfected patients [1]. A calcified mitral ring has been shown to be a predisposing factor for paravalvular leakage [1] as well as a redo operation [4]. A left ventricular–coronary sinus fistula complicating mitral valve replacement is infrequent with only a few patients having been reported as yet [5–7]. Left ventricular–right atrial fistulas after mitral valve replacement are very rare and only 6 cases have yet been published [5, 8–11].
For the anatomic basis of the pathogenesis of left ventricular–right atrial fistulas it is important to realize the higher origin of the septal leaflet of the mitral valve out of the central fibrous tissue of the heart compared to the septal leaflet of the tricuspid valve. These anatomic details are also the background of congenital left ventricular–right atrial fistulas that usually occur combined with defects in the septal leaflet of the tricuspid valve [12]. Extensive debridement of the mitral ring in its anterior portion can thus lead to a shunt by direct communication between the left ventricle and the right atrium through a structural defect. In all published cases of left ventricular–right atrial fistulas after mitral valve replacement the mitral ring was either strongly calcified or an extensive amount of fibrous tissue had to be removed [5, 8–11]. A similar mechanism can lead to the somewhat more frequent left ventricle–coronary sinus communication [5–7], in which the defect is more inferior and posterior. In the present patient extensive decalcification was necessary during the first mitral valve replacement, and removal of additional calcium as well as scar surrounding the valve prosthesis lead to the defect.
These defects have been closed with pledgeted sutures [5, 8–11] either during mitral valve replacement [9, 10], early postoperatively [11], or months after valve replacement [5, 8, 9].
In the present case we decided to use a patch of autologous pericardium to minimize tension on the sutures in the tricuspid ring and to avoid induction of an atrioventricular block [12]. Mattress sutures were used as they could be placed into the central fibrous tissue of the heart like the mitral and tricuspid ring.
We conclude that if patients do not recover sufficiently after mitral valve replacement and a new systolic heart murmur is found, not only paravalvular leakage but also the prevalence of a left ventricular–coronary sinus or a left ventricular–right atrial fistula should be considered. To confirm the diagnosis of an intracardiac shunt, transthoracic and transesophageal color Doppler echocardiography or cardiac catheterization are sufficient tools. If the diagnosis of an intracardiac shunt is made, elective closure should be performed as soon as possible.
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References
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Abstract
Introduction
