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Table of Contents
CASE REPORT  
Year : 2020  |  Volume : 23  |  Issue : 1  |  Page : 103-105
Iatrogenic aortic regurgitation following primary closure of ventricular septal defect: Role of transesophageal echocardiography


1 Department of Anesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India
2 Department of Cardiovascular and Thoracic Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India

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Date of Submission14-Dec-2018
Date of Decision20-May-2019
Date of Acceptance31-May-2019
Date of Web Publication07-Jan-2020
 

   Abstract 


Iatrogenic valvular regurgitation following cardiac surgery has been reported as a result of leaflet perforation or entrapment. Due to its central location, the aortic valve is one of the most vulnerable structures for iatrogenic injuries. Proper assessment of the aortic valve by transesophageal echocardiography(TEE) should be done after a cardiac surgery in the periaortic area. We hereby report a case of iatrogenic aortic regurgitation which was developed after primary closure of perimembranous ventricular septal defect. It was timely diagnosed by TEE after termination of cardiopulmonary bypass and helped in further management.

Keywords: Iatrogenic aortic regurgitation, transesophageal echocardiography, ventricular septal defect

How to cite this article:
Gourav KP, Aspari A, Amburu V, Thingnam SS, Negi S. Iatrogenic aortic regurgitation following primary closure of ventricular septal defect: Role of transesophageal echocardiography. Ann Card Anaesth 2020;23:103-5

How to cite this URL:
Gourav KP, Aspari A, Amburu V, Thingnam SS, Negi S. Iatrogenic aortic regurgitation following primary closure of ventricular septal defect: Role of transesophageal echocardiography. Ann Card Anaesth [serial online] 2020 [cited 2020 Mar 29];23:103-5. Available from: http://www.annals.in/text.asp?2020/23/1/103/275297





   Introduction Top


Surgical closure of ventricular septal defect(VSD) is commonly performed in pediatric cardiac surgery. It is associated with various complications such as complete heart block, infection, postoperative bleeding requiring re-exploration, residual VSD, valve injury, infective endocarditis, pulmonary hypertension with poor cardiac output, and death. Intraoperative transesophageal echocardiographic(TEE) assessment following VSD closure assesses not only the adequacy of VSD closure or left ventricular function but also the iatrogenic injury to the adjacent cardiac structures. We hereby report a case in which TEE has clearly demarcated the distortion of the aortic valve(AV) leading to the development of aortic regurgitation(AR) following direct closure of small perimembranous VSD.


   Case Report Top


A 12-year-old male child was presented to our institute with complaints of shortness of breath and recurrent respiratory tract infections for 6months. On physical examination, the patient had a heart rate of 89/min, blood pressure of 112/64mmHg, respiratory rate 20/min, and oxygen saturation was 99% on room air. The transthoracic echocardiographic assessment revealed a 5-mm perimembranous VSD with a left to right shunt, without any signs of pulmonary artery hypertension, left superior vena cava opening into the right atrium through the coronary sinus, and dilated left atrium and left ventricle. In addition, an indirect type of Gerbode shunt was detected in parasternal AV short-axis view[[Figure1] and Video 1]. Due to the small size of VSD, primary closure of VSD was planned. In the operating room, cannulation of the left-hand dorsal vein was done after instituting standard American Society of Anesthesiologist monitoring. Anesthesia was induced according to the institute protocol. Cannulation of the right radial artery and right internal jugular vein was accomplished after induction of anesthesia. ATEE probe(6VT-D; GE Healthcare; vivid E9; Norway) was inserted, and preoperative TTE findings were confirmed [[Figure2] and Video 2]. The cardiopulmonary bypass(CPB) was initiated after standard aorta bicaval cannulation. Primary closure of VSD was done with pledgeted Prolene 5-0 sutures. The CPB was terminated successfully without any inotropic support. Immediately after termination of CPB, an eccentric AR of moderate severity was detected in TEE which was not present before the surgery[[Figure3] and Video 3]. This eccentric AR was manifested due to the development of traction on the right coronary cusp from the adjacent tissue due to the direct closure of the VSD. Hence, the revision of surgery was planned. The takedown of direct closure of VSD was done under CPB, and it was closed with polytetrafluroethylene patch. The severity of AR was decreased to trivial after revision of surgery [[Figure4] and Video 4]. The patient was shifted to the intensive care unit with stable hemodynamics without any inotropic support. The trachea was extubated after 4 h and he was shifted to the ward after 2days without any sequelae.
Figure 1: A transthoracic echocardiographic image showing a small perimembranous ventricular septal defect(VSD) with Gerbode defect in parasternal aortic valve short-axis view(AO, ascending aorta; LA, left atrium; RA, right atrium; RV, right ventricle)

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Figure 2: A transesophageal echocardiographic image showing a small perimembranous ventricular septal defect(VSD) with left to right shunt in midesophageal aortic valve long-axis view(AO, ascending aorta; LA, left atrium; LV, left ventricle; RV, right ventricle)

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Figure 3: A midesophageal aortic valve long-axis view showing an eccentric aortic regurgitation of moderated severity developed after primary closure of ventricular septal defect(AO, ascending aorta; LA, left atrium; LV, left ventricle; RV, right ventricle)

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Figure 4: An image taken in midesophageal aortic valve long-axis view after patch closure of ventricular septal defect showing no or trivial aortic regurgitation(AO, ascending aorta; CPB, cardio pulmonary bypass; LA, left atrium; LV, left ventricle; RV, right ventricle)

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   Discussion Top


Iatrogenic valvular regurgitation following cardiac procedures has been reported as a result of leaflet perforation or entrapment. Due to its central location, the AV appears to be more vulnerable than the mitral valve.[1] In the index case, the traction developed on the right coronary cusp from the adjacent tissue due to the direct closure of VSD leading to the development of coaptation defect resulting in moderate eccentric AR. Various mechanisms have been suggested for the development of AR which include AV leaflet perforation, inadvertent suture placement, or leaflet tension. It has been documented mostly as case reports and some as case series. Hill etal.[2] reported six cases of iatrogenic AR following non-AV surgeries, out of which two underwent AV repair, two had AV replacement, one required heart transplant, and one died due to transfusion reaction before any intervention. Ducharme etal.[3] found severe AR following insertion of a Carpentier ring during mitral valve repair, which got corrected by releasing few sutures on the annuloplasty ring. Aboelnasr and Rohn [4] documented a case of severe AR, due to perforation of the non-coronary cusp(NCC) after mitral valve repair. The perforated NCC was repaired with a pericardial patch. Asimilar case was reported by Dogan etal.[5]

Iatrogenic AR was also documented following repair of congenital heart disease. Rey etal.[6] reported a perforation of the NCC of AV following repair of ostium primum atrial septal defect in eight children. Zhang etal.[7] reported a case of iatrogenic AR, following VSD closure requiring repair using the pericardial patch. Sabzi etal.[8] reported a case of a 15-year-old boy who underwent VSD closure with Dacron patch leading to the development of AR due to the separation of NCC of AV from its ring caused by tension produced by the Dacron patch pulling on the neighboring tissue. Iatrogenic AR is also reported following left ventricular myectomy.[9] Iatrogenic AR was also documented in the noncardiac case where Kirschner wires while wiring right clavicle fracture had migrated across the AV leading to the development of acute AR.[10] The Kirschner wires were successfully removed, and AV replacement was done.

The intraoperative TEE is vastly recommended for open heart surgeries. It plays an important role in diagnosing accidental injury to adjacent cardiac structures during cardiac surgeries. Rother etal.[11] reported a case of mitral valve (MV)repair for severe mitral regurgitation was found to have a non-mobile left coronary cusp of the AV on intraoperative TEE, causing moderate AR. Similarly, Santiago etal.[12] reported a case in which TEE diagnosed a severe AR due to the restricted motion of left coronary cusp of AV following coronary artery bypass grafting and MV saddle ring repair. Importance of three-dimensional(3D) TEE over two-dimensional TEE was reported by Babu etal.[13] in a case where 3D TEE helped in delineating the cause for aortic sinus distortion after mitral valve replacement and helped in successful intervention. In the index case, the distortion of RCC and moderate AR was timely identified by the intraoperative TEE and helped in the revision of surgery.

In summary, due to its central location, the AV is one of the most vulnerable structures for iatrogenic injuries. Primary closure of perimembranous VSD should be done under caution as it can lead to AR due to the development of traction on the aortic cusp. To the best of our knowledge, this is the first case reporting an iatrogenic AR developed after primary closure of perimembranous VSD, which was diagnosed intraoperatively by TEE and helped in further management.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
KolakalapudiP, ChaudhryS, OmarB. Iatrogenic aortic insufficiency following mitral valve replacement: Case report and review of the literature. JClin Med Res 2015;7:485-9.  Back to cited text no. 1
    
2.
HillAC, BansalRC, RazzoukAJ, LiuM, BaileyLL, GundrySR. Echocardiographic recognition of iatrogenic aortic valve leaflet perforation. Ann Thorac Surg 1997;64:684-9.  Back to cited text no. 2
    
3.
DucharmeA, CourvalJF, DoreA, LeclercY, TardifJC. Severe aortic regurgitation immediately after mitral valve annuloplasty. Ann Thorac Surg 1999;67:1487-9.  Back to cited text no. 3
    
4.
AboelnasrM, RohnV. Aortic valve leaflet perforation after mitral valve repair. Prague Med Rep 2013;114:172-6.  Back to cited text no. 4
    
5.
DoganM, AcikelS, ArslantasU, CimenT, YeterE. Inadvertent complication of prosthetic valve surgery: Leaflet perforation. Acta Medica(Hradec Kralove) 2013;56:167-9.  Back to cited text no. 5
    
6.
ReyC, VaksmannG, BreviereGM, FrancartC, DupuisC.[Aortic valve insufficiency: An unrecognized complication of the surgical repair of ostium primum atrial septal defect]. Arch Mal Coeur Vaiss 1991;84:627-31.  Back to cited text no. 6
    
7.
ZhangT, JiangS, WangY, ChengM, ChengT, GaoC. Surgery on a patient with iatrogenic aortic valve leaflet perforation after repair of a congenital ventricular septal defect. Heart Surg Forum 2013;16:E103-6.  Back to cited text no. 7
    
8.
SabziF, TeimouriH, MoloodiA. Subacute aortic regurgitation as a rare presentation of iatrogenic aortic valve leaflet perforation. Acta Medica Iranica 2009;47:499-501.  Back to cited text no. 8
    
9.
AltarabshehSE, DearaniJA, BurkhartHM, SchaffHV, DeoSV, EidemBW, etal. Outcome of septal myectomy for obstructive hypertrophic cardiomyopathy in children and young adults. Ann Thorac Surg 2013;95:663-9.  Back to cited text no. 9
    
10.
SivasubramanianS, PonnusamySS, RamanKT, PillaiVV. An unusual cause of iatrogenic aortic regurgitation. JAm Coll Cardiol 2013;62:1488.  Back to cited text no. 10
    
11.
RotherA, SmithB, AdamsDH, CollardCD. Transesophageal echocardiographic diagnosis of acute aortic valve insufficiency after mitral valve repair. Anesth Analg 2000;91:499-500.  Back to cited text no. 11
    
12.
SantiagoM, El-DayemMA, DimitrovaG, AwadH. Missed diagnosis of iatrogenic acute aortic insufficiency after mitral valve surgery. Int Anesthesiol Clin 2011;49:26-31.  Back to cited text no. 12
    
13.
BabuS, KoniparambilUP, KumarM, RadhakrishnanBK, AggarwalN, NandaS. Distortion of aortic valve from mechanical traction imposed by the mitral valve prosthesis: The three-dimensional transesophageal echocardiographic perception. Ann Card Anaesth 2017;20:472-4.  Back to cited text no. 13
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Correspondence Address:
Krishna P Gourav
Department of Anesthesia and Intensive Care, Fellow in Cardiac Anesthesia, Post Graduate Institute of Medical Education and Research, Chandigarh - 160 012
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/aca.ACA_238_18

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