Year : 2020  |  Volume : 23  |  Issue : 1  |  Page : 103--105

Iatrogenic aortic regurgitation following primary closure of ventricular septal defect: Role of transesophageal echocardiography


Krishna P Gourav1, Azeez Aspari1, Vamsidhar Amburu1, Shyam S Thingnam2, Sunder Negi1,  
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

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

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.



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;23:103-105


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 2022 Oct 7 ];23:103-105
Available from: https://www.annals.in/text.asp?2020/23/1/103/275297


Full Text



 Introduction



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



A 12-year-old male child was presented to our institute with complaints of shortness of breath and recurrent respiratory tract infections for 6 months. On physical examination, the patient had a heart rate of 89/min, blood pressure of 112/64 mmHg, 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 [[Figure 1] 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. A TEE probe (6VT-D; GE Healthcare; vivid E9; Norway) was inserted, and preoperative TTE findings were confirmed [[Figure 2] 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 [[Figure 3] 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 [[Figure 4] 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 2 days without any sequelae.{Figure 1}{Figure 2}{Figure 3}{Figure 4}[MULTIMEDIA:1][MULTIMEDIA:2][MULTIMEDIA:3][MULTIMEDIA:4]

 Discussion



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 et al.[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 et al.[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. A similar case was reported by Dogan et al.[5]

Iatrogenic AR was also documented following repair of congenital heart disease. Rey et al.[6] reported a perforation of the NCC of AV following repair of ostium primum atrial septal defect in eight children. Zhang et al.[7] reported a case of iatrogenic AR, following VSD closure requiring repair using the pericardial patch. Sabzi et al.[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 et al.[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 et al.[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 et al.[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.

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