Obstruction of mechanical mitral valves by preserved posterior leaflet remnants
Ugur Coskun, Onur Baydar, Gurkan Cetin & Mehmet Serdar Kucukoglu
Journal of Echocardiography ISSN 1349-0222 Volume 11 Number 1 J Echocardiogr (2013) 11:23-25 DOI 10.1007/s12574-012-0156-7
1 23
Your article is protected by copyright and all rights are held exclusively by Japanese Society of Echocardiography. This e-offprint is for personal use only and shall not be selfarchived in electronic repositories. If you wish to self-archive your work, please use the accepted author’s version for posting to your own website or your institution’s repository. You may further deposit the accepted author’s version on a funder’s repository at a funder’s request, provided it is not made publicly available until 12 months after publication.
1 23
Author's personal copy J Echocardiogr (2013) 11:23–25 DOI 10.1007/s12574-012-0156-7
CASE REPORT
Obstruction of mechanical mitral valves by preserved posterior leaflet remnants Ugur Coskun • Onur Baydar • Gurkan Cetin Mehmet Serdar Kucukoglu
•
Received: 28 August 2012 / Revised: 2 October 2012 / Accepted: 9 October 2012 / Published online: 11 November 2012 Ó Japanese Society of Echocardiography 2012
Abstract We report two cases of mechanical prosthetic mitral valve obstruction caused by remnants of the mitral valve posterior leaflet tissue preserved from the previous surgery. Both patients had rheumatic mitral stenosis causing New York Heart Association class III symptoms prior to mitral valve replacement. Keywords Mitral valve Cinefluoroscopy Preserved posterior leaflet Reoperation Introduction Preservation of the mitral valve complex during mitral valve replacement (MVR) surgery has been investigated in several studies in the last 3 decades [1–3]. This procedure has been shown to have positive effects on the skeletal structure and the heart’s axis, avoiding potential changes to the geometry of the left ventricle. In this article, we report two cases of mechanical prosthetic mitral valve obstruction caused by remnants of the mitral valve posterior leaflet tissue preserved during the previous surgery. Case 1 A 63-year-old female who had undergone mitral valve replacement (Sorin-Carbomedics Mitral no. 27) with U. Coskun O. Baydar (&) M. S. Kucukoglu Department of Cardiology, Istanbul University Institute of Cardiology, Haseki, Aksaray 34350, Istanbul, Turkey e-mail:
[email protected] G. Cetin Department of Cardiovascular Surgery, Istanbul University Institute of Cardiology, Haseki, Aksaray 34350, Istanbul, Turkey
preservation of the posterior leaflet and tricuspid annuloplasty 19 years before because of rheumatic mitral valve stenosis was admitted with complaints of progressive dyspnea and palpitation at rest for 2 months. The international normalized ratio (INR) was at therapeutic levels. On transthoracic echocardiography (TTE), prosthetic mitral valve motion did not seem to be normal, and Doppler examination of the valve showed a 10 mmHg mean and 18 mmHg peak gradient. Estimated peak systolic pulmonary artery pressure (PAP) was 60 mmHg. The cinefluroscopy showed that the posterior leaflet of the prosthetic mitral valve was motionless in the closed position. On the transesophageal echocardiography (TEE), there was no vegetation or thrombus causing the mechanical valve failure (Fig. 1). The patient underwent surgical repair. Residual tissue, restricting the motion of the prosthetic mitral valve, was resected, and the old valve in mitral position was replaced with a no. 27 St. Jude bileaflet mechanical mitral valve. The patient was asymptomatic in routine controls.
Case 2 A 37-year-old male, who had undergone mitral valve replacement (Bjo¨rk-Shiley no. 29) with posterior leaflet preservation for rheumatic mitral stenosis in 2002, was admitted with our hospital with heart failure symptoms. The INR was at therapeutic levels. On TTE, there was a 26 mmHg mean and 51 mmHg peak gradient across the prosthetic mitral valve, and severe tricuspid regurgitation was detected. Estimated peak systolic PAP was 58 mmHg. Cinefluoroscopy was performed, and restricted opening of the monoleaflet prosthetic mitral valve was detected (opening angle was 20°; normal value is 54°–60° for the Bjo¨rk-Shiley valve) [4]. On the TEE, there was no
123
Author's personal copy 24
J Echocardiogr (2013) 11:23–25
Fig. 1 Bileaflet mechanical mitral valve cinefluoroscopy and TEE image shows that the posterior leaflet of the prosthetic mitral valve was motionless in the closed position
Fig. 2 Monoleaflet mechanical mitral valve cinefluoroscopy and TEE image show the restricted opening of the monoleaflet prosthetic mitral valve
vegetation or thrombus (Fig. 2). Subvalvular residual tissue was resected, and the old mechanical mitral valve replaced with a no. 29 St. Jude bileaflet mitral valve. The patient was asymptomatic in controls.
Discussion The most common cause of extrinsic obstruction is thrombus formation on or around the prosthesis [5]. Other
123
rare causes of obstruction include vegetations in infective endocarditis, entrapment of left ventricular myocardium, granulation tissue, suture entanglement, and peri-annular fibrosis. Prosthetic valve obstruction due to subvalvular residual tissues is a rare complication. Previously reported cases related to this mechanism have all occurred within the immediate postoperative period [5, 6]. Our two patients had undergone mitral valve replacement with preservation of the posterior leaflet and were reoperated because of recurrent decompensated heart failure symptoms caused by
Author's personal copy J Echocardiogr (2013) 11:23–25
restriction of prosthetic valve opening years after the original surgery. The risk of this complication can be minimized by careful valvular excision, including removal of the chordal tissue, proper prosthesis selection, and meticulous suturing techniques [6].
25
3.
4. Conflict of interest There are no relationships with industry or financial associations that might pose a conflict of interest. 5.
References 6. 1. Asano K, Furuse A. Techniques of modified mitral valve replacement with preservation of the posterior leaflet and chordae tendineae. Thorac Cardiovasc Surg. 1987;35:206–8. 2. Yagyu K, Matsumoto H, Asano K. Importance of the mitral complex in left ventricular contraction—n analysis of the results of
mitral valve replacement with preservation of the posterior mitral complex. Thorac Cardiovasc Surg. 1987;35:166–71. Patel H, Antoine SM, Funk M, et al. Left ventricular outflow tract obstruction after bioprosthetic mitral valve replacement with preservation of the anterior leaflet. Rev Cardiovasc Med. 2011;12:48–51. Montorsi P, De Bernardi F, Muratori M, et al. Role of cinefluoroscopy, transthoracic, and transesophageal echocardiography in patients with suspected prosthetic heart valve thrombosis. Am J Cardiol. 2000;85:58–64. Greenwood JP, Nolan J, Mackintosh AF. Late, intermittent obstruction of a mitral prosthesis by chordal remnants. Eur J Cardiothorac Surg. 1997;12:804–6. Pai GP, Ellison RG, Rubin JW, et al. Disc immobilisation of Bjork-Shiley and Medtronic-Hall valves during and immediately after valve replacement. Ann Thorac Surg. 1987;44:73–6.
123
