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INTERESTING IMAGE Table of Contents   
Year : 2008  |  Volume : 11  |  Issue : 2  |  Page : 127-128
An unusual complication following mitral valve surgery and use of intra-operative transoesophageal echocardiography


Department of Anaesthesiology and Narayana Hrudayalaya, Bangalore, India

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How to cite this article:
Murugesan C, Banakal S, Muralidhar K. An unusual complication following mitral valve surgery and use of intra-operative transoesophageal echocardiography. Ann Card Anaesth 2008;11:127-8

How to cite this URL:
Murugesan C, Banakal S, Muralidhar K. An unusual complication following mitral valve surgery and use of intra-operative transoesophageal echocardiography. Ann Card Anaesth [serial online] 2008 [cited 2020 Jan 20];11:127-8. Available from: http://www.annals.in/text.asp?2008/11/2/127/41583


Prosthetic leaflet immobilisation has been described in mitral valve prostheses following mitral valve replacement surgery. [1] Stuck or immobile prosthetic valve is a relatively uncommon condition and it is a potentially life-threatening complication of mitral valve replacement surgery. Transoesophageal echocardiography (TOE) has been instrumental in the early detection of prosthetic valve malfunction following cardiopulmonary bypass. [2]


   Case Report Top


A 38-year-old patient, a known case of rheumatic heart disease with severe mitral regurgitation was scheduled for mitral valve surgery. Intra-operative pre-cardiopulmonary bypass (CPB) TOE revealed prolapse of posterior mitral leaflet, ruptured chordae of P2 scallop of the posterior mitral leaflet, thickened posterior mitral leaflet (PML), and calcified posterior aspect of mitral annulus [Figure 1],[Figure 2]. Mitral valve repair was performed with quadrangular resection of PML and placing a Carpentier-Edwards mitral annuloplasty ring (no. 28 size). Since there was significant regurgitation following repair, which was assessed by injecting saline into the left ventricle, it was decided to do mitral valve replacement with no. 27 mm Medtronic prosthetic valve along with partial preservation of PML. Left ventricular cavity was inspected carefully before seating the prosthetic valve. While separating from CPB, the arterial waveform did not show any ejections in the monitor even though the heart was contracting vigorously. TOE revealed completely immobile prosthetic leaflet in closed position with spontaneous echo contrast in the left atrium (LA) [Figure 3]. Distended LA with bulging of inter-atrial septum toward the right atrium was also seen on TOE. Right ventricle was distended on inspection of the surgical field. CPB was reinstituted to inspect the mitral valve under cardioplegic arrest. A thin, free-floating tertiary order chordae was seen between the valve disc and sewing ring, resulting in leaflet immobility. After removal of chordal element, free excursion of the disc was ensured. Patient was successfully separated from CPB after removal of the chordal tissues. Post-CPB TOE showed normal excursion of the prosthetic mitral leaflet [Figure 4].


   Discussion Top


Stuck prosthetic mitral valve is a relatively rare occurrence following mitral valve replacement. Occasionally, it causes life-threatening complication. Its incidence and treatment are not well defined. [3] There are several mechanisms involved in prosthetic leaflet immobilisation. This is, commonly, due to obstruction by mitral subvalvular apparatus. [4] Other mechanisms for immobile prosthetic valve (unileaflet tilting disc valve) are (a) left ventricular myocardium impeding the free movement of prosthetic valve, (b) immobilisation of disc valve by an unravelled suture. [5],[6]

Needless to say, that delay in the detection of stuck prosthetic valve would have resulted in myocardial distension injury, haemodynamic deterioration, and failure to wean from cardiopulmonary bypass. Hiroshi kumano et al. [2] encountered a rare complication of mitral valve replacement with the CarboMedics prosthesis: A "stuck" leaflet detected by TOE even though weaning from CPB had been uneventful. The patient was immediately managed without significant problems.

TOE examination provides the surgical team with a definitive evaluation of valvular function (both qualitative and quantitative) immediately after CPB, thereby allowing early surgical intervention, if necessary, and flawed repairs to be corrected before the patient leaves the operating room (OR). [7]

 
   References Top

1.Shahid M, Sutherland G, Hatle L. Diagnosis of intermittent obstruction of mechanical valve prostheses by Doppler echocardiography. Am J Cardiol 1995;76:1305-9.  Back to cited text no. 1    
2.Kumano H, Suehiro S, Shibata T, Hattori K, Kinoshita H. Stuck valve leaflet detected by intraoperative transesophageal echocardiography. Ann Thorac Surg 1999;67:1484-5.  Back to cited text no. 2    
3.Sante P. Acute postoperative block of mechanical prostheses: Incidence and treatment. Cardiovasc Surg 1994;2:403-6.  Back to cited text no. 3    
4.Singh A, Nanda NC, Kirklin JK. Intraoperative transesophageal echocardiographic diagnosis of a stuck bioprosthetic mitral valve leaflet. Echocardiography 2007;24:436-8.  Back to cited text no. 4    
5.Pai GP, Ellison RG, Rubin JW, Moore HV, Kamath MV. Disc immobilization of Bj φrk-Shiley and Medtronic Hall valves during and immediately after valve replacement. Ann Thorac Surg 1987;44:73-6.  Back to cited text no. 5    
6.Actis Dato GM, Bognolo G, Actis Dato A Jr, Cattaneo C, Di Summa M. A rare complication of mitral valve replacement: Sudden cardiac death for immobilization of disc valve by an unraveled suture. J Cardiovasc Surg (Torino) 1995;36:167-9.  Back to cited text no. 6    
7.Sheikh KH, de Bruijn NP, Rankin JS, Clements FM, Stanley T, Wolfe WG, et al . The utility of transesophageal echocardiography and Doppler color flow imaging in patients undergoing cardiac valve surgery. J Am Col Cardiol 1990;15:363-72.  Back to cited text no. 7    

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Correspondence Address:
Chinnamuthu Murugesan
Narayana Hrudayalaya, Bommasandra Industrial Area, Anekal Taluk, Bangalore
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9784.41583

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