Ann Thorac Surg 2008;85:311-313. doi:10.1016/j.athoracsur.2007.07.101
© 2008 The Society of Thoracic Surgeons
Case Reports
Subannular Perforation After Long-Lasting Aortic Valve Replacement Mimicking Mitral Insufficiency
Justus T. Strauch, MDa,*,
Jens Wippermann, MDa,
Henning Krep, MDb,
Thorsten Wahlers, MDa
a Department of Cardiothoracic Surgery, University Hospital Cologne, Cologne, Germany
b Department of Anesthesiology, University Hospital Cologne, Cologne, Germany
Accepted for publication July 24, 2007.
* Address correspondence to Dr Strauch, Department of Cardiothoracic Surgery, University Hospital of Cologne, Kerpener Str 62, Cologne, 50924, Germany (Email: ju.strauch{at}gmx.de).
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Abstract
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We report a rare case of a patient diagnosed with mitral insufficiency grade III 12 years after mechanical aortic valve replacement. Transesophageal echocardiography discribed an eccentric mitral regurgitation-type systolic jet with color flow evidence of communication between left venticle and atrium. Surgical intervention showed a circular defect in the mitral-aortic intervalvular fibrosa area, after removal of the mechanical valve, located beneath the noncoronary sinus causing the echocardiography-detected mitral insufficiency. A pericardial patch was trimmed to the appropriate size, and the defect was closed. The aortic valve was replaced by a stented pericardial bioprosthesis.
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Introduction
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It is rarely reported in patients with aortic valve endocarditis that structural damage may occure to the mitral-aortic intervalvular fibrosa and the anterior mitral leaflet [1]. As a consequence, a perforation and communication between the left atrium and the left ventricular outflow tract emerges, resulting in systolic regurgitation of blood into the left atrium [2]. The described phenomen may be followed by perforation of the anterior mitral leaflet.
A 72-year-old man was referred to us by cardiology with a recently diagnosed mitral insufficiency grade III and concomitant coronary heart disease. The patient had a status post mechanical aortic valve (23 mm) replacement 12 years ago. Aortic valve examination showed adequate valve function as demonstrated by echocardiography examination.
Operation was performed under intraoperative transesophageal echocardiography. Examination revealed some "shagginess" around the noncoronary sinus of valsalva, an eccentric mitral regurgitation-type systolic jet with color-flow evidence of communication between left venticle and atrium. No aortic regurgitation was noted by color-flow imaging (Fig 1). The mechanical aortic valve appeared to be functional. Global left ventricular function was not compromised; there were no signs of pericardial effusions. The blood chemistries were within the normal limits except for hemoglobin, hematocrit, serum glutamic-oxaloacetic transaminase, and serum glutamic-pyruvic transaminase. No signs of active infectious endocarditis were seen.
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Fig 1. Preoperative transesophageal echocardiography with color demonstrating an eccentric mitral regurgitation-type systolic jet resulting from perforation of the mitral-aortic intervalvular fibrosa.
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At surgery, an aortotomy and a left atriotomy were performed. The aortic valve prosthesis was without pathologic findings, especially no signs for paravalvular leakage were detected. No clear pathologic evidence for the above described phenomenon of mitral regurgitation was obtained by examination of the left atrium. So the decision was made to remove the mechanical aortic valve prosthesis. Immediately after prosthesis removal, a circular defect of 3 to 4 mm in diameter was found in the mitral-aortic intervalvular fibrosa area located beneath the noncoronary sinus, causing the echocardiography-detected mitral insufficiency jet into the left atrium. The anterior mitral valve leaflet was without any structural damage, and the mitral annulus was not interrupted (Fig 2). A 5 x 5 mm pericardial patch was trimmed to the appropriate size, and the defect was closed by sewing the patch into the hole using four 5-0 unpledgeted polypropylene single sutures (Fig 3). The aortic valve was replaced by a 23-mm stented pericardial bioprosthesis.
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Fig 2. Intraoperative specimen after removal of the mechanical aortic valve prosthesis showing the perforation between left ventricular outflow tract and left atrium.
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The postoperative course was uneventful, and the patient was discharged on the ninth postoperative day on a regimen of vitamin K antagonist anticoagulation therapy for 3 months. Echocardiogram at the time of discharge showed normal function of the aortic valve prosthesis and no residual shunt flow.
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Comment
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The anterior leaflet of the mitral valve lies in a somewhat medial position, subjacent to the noncoronary sinus of the aortic valve. This junctional zone between the two valves is formed by fibrous annular tissue and has been called the mitral-aortic intervalvular fibrosa [1]. This area may be involved in infections of both valves. As a very rare complication, mitral-aortic intervalvular fibrosa perforation in the absence of infectious endocarditis into the left atrium is possible. Eventually, theoretically, we see a former healed endocarditis responsible for the described, very localized lesion. We see this theory supported by the intraoperative findings as there were very plain edges of the perforation (Fig 2), no signs of an abscess cavity, an absence of infectious endocarditis signs in the past, and no signs of thrombus on the valve prosthesis.
Even though this complication should be as precisely diagnosed before surgery as possible, there remains the risk that the eccentric jet can be overlooked because of suboptimal preoperative echocardiographic visualization and direct view of this region by the surgeon [3]. Surgeons should be encouraged to scrutinize the mitral-aortic intervalvular fibrosa region, also taking the removal of the valve beforehand into consideration.
In conclusion, any presence of an eccentric mitral regurgitation type of jet by color-flow imaging, even in the absence of infectious endocarditis after previous heart valve surgery, may alert the surgeon to the described complication in the vulnerable mitral-aortic intervalvular fibrosa region. This relatively avascular structure may be easily impaired for the previously reported reasons. To our knowledge, the incidence is less than 1 per 1,000, certainly marginally higher in the group of patients having previous aortic or mitral valve operations.
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References
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- Karalis DG, Bansal RC, Hauck AJ, et al. Transesophageal echocardiographic recognition of subaortic complications in aortic valve endocarditis—clinical and surgical implications Circulation 1992;86:353-362.[Abstract/Free Full Text]
- Tak T. Pseudoaneurysm of mitral-aortic intervalvular fibrosa Clin Med Res 2003;1:149-152.
- Bansal RC, Graham BM, Jutzy KR, Shakudo M, Shah PM. Left ventricular outflow tract to left atrial communication secondary to rupture of mitral-aortic intervalvular fibrosa in infective endocarditis: diagnosis by transesophageal echocardiography and color flow imaging J Am Coll Cardiol 1990;15:499-504.[Abstract]
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Abstract
Introduction
