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An Unusual Case of Severe Mitral Regurgitation Due to a Focal Large Peri-Ring Defect in a Patient With Mitral Valve Repair
An Unusual Case of Severe Mitral Regurgitation Due to a Focal Large Peri-Ring Defect in a Patient With Mitral Valve Repair Mohammad Q. Najib, MD, Hari P. Chaliki, MD, Satya S. Vittala, MBBS, Amol Raizada, MD, and Roger L. Click, MD, PhD Divisions of Cardiovascular Diseases, Mayo Clinic, Scottsdale, Arizona; and Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
Fig 1.
A
60-year-old man with exertional dyspnea and moderate-to-severe mitral valve regurgitation diagnosed at another facility was referred to our tertiary care academic medical center for further care. His medical history was significant for chronic atrial fibrillation and mitral valve repair at 48 years of age. A coronary angiogram showed normal coronary arteries. A transthoracic echocardiogram demonstrated severe left atrial enlargement and eccentric moderate-to-severe mitral valve regurgitation. The annuloplasty ring appeared intact, with no obvious mitral valve prolapse. A prebypass realtime three-dimensional transesophageal echocardiogram showed a focal large periring defect (left ventriculo–left atrial fistula; Fig 1A, arrow; AV, aortic valve). Color flow Doppler revealed severe posteromedial periprosthetic miAddress correspondence to Dr Chaliki, Division of Cardiovascular Diseases, Mayo Clinic, 13400 E Shea Blvd, Scottsdale, AZ 85259; e-mail: [email protected].
© 2012 by The Society of Thoracic Surgeons Published by Elsevier Inc
tral ring regurgitation (Fig 1B; LA, left atrium; LV, left ventricle) originating from a large periring defect (Fig 1C, arrow; Ao, aorta; LA, left atrium; LV, left ventricle). The echocardiographic images clearly showed that the posterior wall of the left atrium and left ventricle were intact as well as the posterior atrioventricular groove (Fig 1C). Most likely this periring defect was due to sutures pulling out from the middle portion of the annulus and the annuloplasty ring leading to a “hole” posterior to the annuloplasty ring within the previously repaired portion of the posterior mitral valve leaflet. These findings were confirmed during surgery. The hole in the mitral valve was repaired again, and the annuloplasty ring was sewn back to the annulus with two interrupted mattress sutures of 2-0 ethibond backed with felt pledgets. These mattress sutures were reinforced by additional 3-0 prolene sutures. A postbypass transesophageal echocardiogram showed trivial to mild residual mitral regurgitation.
Ann Thorac Surg 2012;93:e165 • 0003-4975/$36.00 doi:10.1016/j.athoracsur.2012.01.001
Fig 1.
A
60-year-old man with exertional dyspnea and moderate-to-severe mitral valve regurgitation diagnosed at another facility was referred to our tertiary care academic medical center for further care. His medical history was significant for chronic atrial fibrillation and mitral valve repair at 48 years of age. A coronary angiogram showed normal coronary arteries. A transthoracic echocardiogram demonstrated severe left atrial enlargement and eccentric moderate-to-severe mitral valve regurgitation. The annuloplasty ring appeared intact, with no obvious mitral valve prolapse. A prebypass realtime three-dimensional transesophageal echocardiogram showed a focal large periring defect (left ventriculo–left atrial fistula; Fig 1A, arrow; AV, aortic valve). Color flow Doppler revealed severe posteromedial periprosthetic miAddress correspondence to Dr Chaliki, Division of Cardiovascular Diseases, Mayo Clinic, 13400 E Shea Blvd, Scottsdale, AZ 85259; e-mail: [email protected].
© 2012 by The Society of Thoracic Surgeons Published by Elsevier Inc
tral ring regurgitation (Fig 1B; LA, left atrium; LV, left ventricle) originating from a large periring defect (Fig 1C, arrow; Ao, aorta; LA, left atrium; LV, left ventricle). The echocardiographic images clearly showed that the posterior wall of the left atrium and left ventricle were intact as well as the posterior atrioventricular groove (Fig 1C). Most likely this periring defect was due to sutures pulling out from the middle portion of the annulus and the annuloplasty ring leading to a “hole” posterior to the annuloplasty ring within the previously repaired portion of the posterior mitral valve leaflet. These findings were confirmed during surgery. The hole in the mitral valve was repaired again, and the annuloplasty ring was sewn back to the annulus with two interrupted mattress sutures of 2-0 ethibond backed with felt pledgets. These mattress sutures were reinforced by additional 3-0 prolene sutures. A postbypass transesophageal echocardiogram showed trivial to mild residual mitral regurgitation.
Ann Thorac Surg 2012;93:e165 • 0003-4975/$36.00 doi:10.1016/j.athoracsur.2012.01.001