Ann Thorac Surg 2003;75:584-586
© 2003 The Society of Thoracic Surgeons
Case report
Left atrial dissection after double valve replacement
Mikio Ninomiya, MD*a,
Shinichi Takamoto, MDa,
Yutaka Kotsuka, MDa,
Toshiya Ohtsuka, MDa
a Department of Cardiothoracic Surgery, Faculty of Medicine, University of Tokyo, Tokyo, Japan
Accepted for publication August 14, 2002.
* Address reprint requests to Dr Ninomiya, 6-15-13-902 Hon-Komagome, Bunkyo-ku, Tokyo 113-0021, Japan.
e-mail: mikio-ninomiya{at}par.odn.ne.jp
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Abstract
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Left atrial dissection, a rare complication occurring mainly after mitral repair, is reported after double valve replacement in a patient with a connective tissue disease. A 63-year-old woman with systemic sclerosis underwent double valve replacement. Laceration of the tissue between the two mechanical prostheses and dissection of the left atrial wall emerged postoperatively and regurgitation through the dissection caused heart failure, which later improved without surgery. The possible causes of the dissection were thought to be shear forces against the tissue between the two prostheses and tissue fragility due to systemic sclerosis and corticosteroid therapy.
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Introduction
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Left atrial dissection is an extremely rare complication occurring mainly after mitral valve repair. We encountered left atrial dissection after mitral and aortic valve replacement in a patient with systemic sclerosis and herein report that case.
A 63-year-old woman who underwent open mitral commissurotomy for rheumatic mitral stenosis in 1974 was referred to our hospital. She had congestive heart failure due to mitral stenosis (mitral valve area was 1.1 cm2), aortic stenosis (pressure gradient was 43 mm Hg), and tricuspid regurgitation since July 2000. She also had progressive systemic sclerosis, which had been treated since 1992 with 2 mg a day of methylprednisolone.
The operation was performed in December 2000. After median sternotomy and adhesiolysis, cardiopulmonary bypass was instituted and cardioplegic arrest was obtained. Although the mitral valve was severely thickened and sclerotic the mitral annulus had no calcified lesion. The anterior mitral leaflet was resected for the subsequent valve replacement with the posterior leaflet being preserved. Before implanting the mitral valve prosthesis the aortic valve was inspected. The aortic valve was also sclerotic and stenotic and aortic valve replacement was conducted using a St. Jude Medical prosthesis (21 mm, St. Jude Medical, St. Paul, MN). The mitral valve prosthesis (St. Jude Medical 25 mm) was then implanted using 14 mattress sutures with Teflon felt pledgets to prevent paravalvular leakage. Under partial cardiopulmonary bypass the right atrium was opened and tricuspid annuloplasty (Kay-Reed procedure) was conducted. Although all these procedures were smoothly performed it took a long time to obtain complete hemostasis because the tissue was extremely fragile, probably due to systemic sclerosis and corticosteroid therapy. The duration of the cardiopulmonary bypass was 217 minutes and that of the aortic cross clamping 111 minutes.
Although routine transesophageal echography (TEE) at the end of the operation showed no abnormality, TEE on the 12th postoperative day showed dehiscence between the mitral and the aortic prostheses and dissection of the aortic side wall of the left atrium (Fig 1A). Color Doppler echocardiography showed a moderate amount of regurgitant flow through the dissected lumen in the systolic phase (Fig 1B), and the regurgitant flow was radiating into the left atrial cavity through a reentry located far from the mitral annulus, indicating it was not a simple paravalvular leakage but left atrial dissection. The patient’s pulmonary congestion did not sufficiently improve postoperatively because of the regurgitation through the dissection and postoperative renal dysfunction, and prolonged intravenous administration of dopamine and diuretic agents was required. Postoperative right cardiac catheterization showed elevated mean pulmonary artery pressure (31 mm Hg) and central venous pressure (17 mm Hg). The patient was transferred to the department of internal medicine for the treatment of systemic sclerosis because her symptoms such as skin lesions, pleuritis, and systemic inflammation recurred postoperatively. The congestive heart failure as well as the systemic sclerosis improved after proper medication. She is now being followed up at our outpatient clinic with regular echocardiography. The regurgitation through the dissected lumen is estimated to be comparable to moderate mitral regurgitation, and the patient fits the New York Heart Association class II category.
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Fig 1. (A) Postoperative transesophageal echocardiography showed the tissue discontinuity between the mitral and the aortic prostheses and the dissection of the aortic side of the left atrial wall (arrow). (B) Color Doppler echocardiography showed a regurgitant flow (arrow) from the left ventricle into the left atrium through the dissected lumen in the systolic phase. (AO = aorta; AV = aortic valve; LA = left atrium; LV = left ventricle; MV = mitral valve.)
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Comment
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Left atrial dissection is a rare complication after mitral valve repair and the literature reveals only a small number of cases [1–6]. Although shear force to the posterior mitral annulus due to surgical maneuvers or annular calcification is the commonest cause of left atrial dissection [3–5] it also occurs in cases with an intact posterior mitral leaflet [1, 2].
Although one case of left atrial dissection after double valve replacement, as in our case, has been reported [6], the details of the pathophysiology were unclear in the paper. The causes of dissection in our case are thought to be the postoperative shear forces against the tissue between the mitral and the aortic prostheses and extreme tissue fragility probably due to systemic sclerosis and corticosteroid therapy. There seemed to be no particular problem in the sizing of the valve prostheses or operative maneuvers.
In most of the previous cases left atrial dissection was surgically treated during [1, 2] or immediately after [3–5] the primary operation using two different types of surgery, namely, internal drainage [1, 2] and entry closure [3–5]. In our case, we treated the dissection conservatively because of the patient’s poor general condition. If it had been possible, we might have conducted re-replacement of the mitral valve with patch closure of the lacerated intima between the mitral and the aortic annuli.
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References
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- Genoni M., Jenni R., Schmid E.R., Vogt P.R., Turina M.I. Treatment of left atrial dissection after mitral repair: internal drainage. Ann Thorac Surg 1999;68:1394-1396.[Abstract/Free Full Text]
- Goda T., Ishii K., Shiiya N., Oba J., Matsui Y., Yasuda K. Acute dissection of the interatrial septum after re-replacement of the mitral valve: a case report. J Jpn Assn Thorac Surg 1994;42:1092-1095.
- Sekino Y., Sadahiro M., Tabayashi K. Successful surgical repair of left atrial dissection after mitral valve replacement. Ann Thorac Surg 1996;61:1528-1530.[Abstract/Free Full Text]
- 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]
- Gallego P., Oliver J.M., Gonzalez A., Dominguez F.J., Sanchez-Recalde A., Mesa J.M. Left atrial dissection: pathogenesis, clinical course, and transesophageal echocardiographic recognition. J Am Soc Echocardiogr 2001;14:813-820.[Medline]
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Abstract
Introduction
