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Iatrogenic Mitral Valve Injury During Aortic Valve Replacement: Importance of Intraoperative Transesophageal Echocardiography
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Iatrogenic Mitral Valve Injury During Aortic Valve Replacement: Importance of Intraoperative Transesophageal Echocardiography To the Editor: We report a rare case of intraoperative iatrogenic injury to the mitral valve, showing the importance of a complete transesophageal echocardiographic (TEE) examination before and after cardiac surgery. A 47-year-old woman with severe aortic insufficiency and coronary artery disease presented for elective aortic valve replacement and singlevessel bypass grafting. Before cardiopulmonary bypass (CPB), TEE revealed severe aortic insufficiency, no other valvular pathology, and preserved left ventricular function. Surgical intervention consisted of an aortic valve replacement (25-mm Epic bioprosthetic; St Jude Medical Inc, St Paul, MN) as well as a saphenous vein graft to the posterolateral branch of the right coronary artery. A TEE examination performed after the separation from CPB confirmed normal function of the aortic valve prosthesis and excellent left ventricular function. However, significant mitral regurgitation from a partially flail anterior leaflet was observed. The surgeon was notified and suspected that injury to the subvalvular apparatus of the mitral valve likely occurred as a result of the removal of an entangled suction catheter inserted into the left ventricular cavity during the operation (Fig 1). CPB was then reinstituted. Upon direct visualization of the mitral valve, the anterior leaflet was found to have 2 ruptured primary cords. Repair was attempted but unsuccessful. As a result, a 25-mm St Jude Epic tissue valve was inserted. After mitral valve replacement TEE revealed normal function of the aortic bioprosthesis, but the mitral valve had a small single paravalvular leak that was not surgically addressed. The patient was taken to the cardiothoracic intensive care unit in stable condition and eventually discharged to a rehabilitation facility.
LETTERS TO THE EDITOR
We were able to find only 1 case report of iatrogenic damage to the mitral valve by a suction catheter during cardiac surgery. In that report, the surgeon visualized the suction coil tangled in a mitral valve cord but was able to stretch the spiral coil in order to remove it safely without causing permanent damage to the valve.1 Our case is unusual in that damage to the mitral valve apparatus did occur, and it was recognized by intraoperative postbypass transesophageal echocardiography. Our findings made it possible for the surgeon to identify the iatrogenic injury and surgically address the valve before sternal closure and departure from the operating room. The American Society of Anesthesiologists Task force on Perioperative Transesophageal Echocardiography recommends all patients undergoing valvular procedures be evaluated with TEE,2 and this case clearly shows the importance of performing a thorough and complete TEE examination of all cardiac structures before and after cardiac surgery. Jennifer Steiman, MD Mark A. Chaney, MD University of Chicago Chicago, IL REFERENCES 1. Agrawal D, Ang KL, Mittal T, et al: Mitral valve injury by cardiotomy suction during aortic valve replacement—A near miss. Interact Cardiovasc Thorac Surg 7:136-137, 2008 2. American Society of Anesthesiologists Task Force on Perioperative Transesophageal Echocardiography: Practice guidelines for perioperative transesophageal echocardiography. Anesthesiology 112:10841096, 2010 doi:10.1053/j.jvca.2010.07.010
Transthoracic Echocardiography in the Intensive Care Unit for the Diagnosis of Right-Ventricle Endocarditis To the Editor:
Fig 1. A cardiac suction catheter inserted into the left ventricular cavity that caused injury to the mitral valve during aortic valve replacement. (Color version of figure is available online.)
Transthoracic echocardiography (TTE) is the only noninvasive method that can offer bedside real-time and dynamic imaging of the heart and pleura. Traditionally, this has been performed solely by cardiologists with extensive training in advanced techniques of TTE. However, a growing body of evidence advocates that noncardiologist physicians can be trained successfully in TTE in the intensive care unit (ICU).1,2 The case reported here involved a 72-year-old man with diabetes mellitus and chronic renal impairment. The patient underwent coronary artery bypass graft surgery and was transferred to the ICU. Although his ICU stay after surgery was prolonged and complicated by urinary catheter–related candiduria, he recovered and regained independence. Ten days after being discharged from the critical care unit, he developed dyspnea and rigors, and he subsequently became confused and experienced urinary incontinence. The initial examination revealed a fever (39°C), normotension, an oximeter reading of 90% (room air), and
Iatrogenic Mitral Valve Injury During Aortic Valve Replacement: Importance of Intraoperative Transesophageal Echocardiography To the Editor: We report a rare case of intraoperative iatrogenic injury to the mitral valve, showing the importance of a complete transesophageal echocardiographic (TEE) examination before and after cardiac surgery. A 47-year-old woman with severe aortic insufficiency and coronary artery disease presented for elective aortic valve replacement and singlevessel bypass grafting. Before cardiopulmonary bypass (CPB), TEE revealed severe aortic insufficiency, no other valvular pathology, and preserved left ventricular function. Surgical intervention consisted of an aortic valve replacement (25-mm Epic bioprosthetic; St Jude Medical Inc, St Paul, MN) as well as a saphenous vein graft to the posterolateral branch of the right coronary artery. A TEE examination performed after the separation from CPB confirmed normal function of the aortic valve prosthesis and excellent left ventricular function. However, significant mitral regurgitation from a partially flail anterior leaflet was observed. The surgeon was notified and suspected that injury to the subvalvular apparatus of the mitral valve likely occurred as a result of the removal of an entangled suction catheter inserted into the left ventricular cavity during the operation (Fig 1). CPB was then reinstituted. Upon direct visualization of the mitral valve, the anterior leaflet was found to have 2 ruptured primary cords. Repair was attempted but unsuccessful. As a result, a 25-mm St Jude Epic tissue valve was inserted. After mitral valve replacement TEE revealed normal function of the aortic bioprosthesis, but the mitral valve had a small single paravalvular leak that was not surgically addressed. The patient was taken to the cardiothoracic intensive care unit in stable condition and eventually discharged to a rehabilitation facility.
LETTERS TO THE EDITOR
We were able to find only 1 case report of iatrogenic damage to the mitral valve by a suction catheter during cardiac surgery. In that report, the surgeon visualized the suction coil tangled in a mitral valve cord but was able to stretch the spiral coil in order to remove it safely without causing permanent damage to the valve.1 Our case is unusual in that damage to the mitral valve apparatus did occur, and it was recognized by intraoperative postbypass transesophageal echocardiography. Our findings made it possible for the surgeon to identify the iatrogenic injury and surgically address the valve before sternal closure and departure from the operating room. The American Society of Anesthesiologists Task force on Perioperative Transesophageal Echocardiography recommends all patients undergoing valvular procedures be evaluated with TEE,2 and this case clearly shows the importance of performing a thorough and complete TEE examination of all cardiac structures before and after cardiac surgery. Jennifer Steiman, MD Mark A. Chaney, MD University of Chicago Chicago, IL REFERENCES 1. Agrawal D, Ang KL, Mittal T, et al: Mitral valve injury by cardiotomy suction during aortic valve replacement—A near miss. Interact Cardiovasc Thorac Surg 7:136-137, 2008 2. American Society of Anesthesiologists Task Force on Perioperative Transesophageal Echocardiography: Practice guidelines for perioperative transesophageal echocardiography. Anesthesiology 112:10841096, 2010 doi:10.1053/j.jvca.2010.07.010
Transthoracic Echocardiography in the Intensive Care Unit for the Diagnosis of Right-Ventricle Endocarditis To the Editor:
Fig 1. A cardiac suction catheter inserted into the left ventricular cavity that caused injury to the mitral valve during aortic valve replacement. (Color version of figure is available online.)
Transthoracic echocardiography (TTE) is the only noninvasive method that can offer bedside real-time and dynamic imaging of the heart and pleura. Traditionally, this has been performed solely by cardiologists with extensive training in advanced techniques of TTE. However, a growing body of evidence advocates that noncardiologist physicians can be trained successfully in TTE in the intensive care unit (ICU).1,2 The case reported here involved a 72-year-old man with diabetes mellitus and chronic renal impairment. The patient underwent coronary artery bypass graft surgery and was transferred to the ICU. Although his ICU stay after surgery was prolonged and complicated by urinary catheter–related candiduria, he recovered and regained independence. Ten days after being discharged from the critical care unit, he developed dyspnea and rigors, and he subsequently became confused and experienced urinary incontinence. The initial examination revealed a fever (39°C), normotension, an oximeter reading of 90% (room air), and