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Left ventricular-coronary sinus fistula after mitral valve replacement
Volume 94 Number 4 October 1987
Left ventricular-coronary sinus fistula after mitral valve replacement Anthony G. Rogers, MD, and Nicholas P. Rossi, MD, Iowa City, Iowa From the Division of Cardiothoracic Surgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa.
One of the more rare complications after mitral valve replacement is the development of a left ventricular-eoronary sinus fistula, which has been reported only twice before. In the reported cases a common feature has been multiple valve replacements. Our case was one of the late development (8 years) of a fistula in a patient who had only one previous replacement but in whom a murmur was detected 3 months after the operation.
Mitral valve replacement has been associated with many complications, which include posterior left ventricular rupture, left ventricular-right atrial fistula, circumflex artery injury, and cardiac rhythm disturbances, among others. I. 2 A rare complication that to our knowledge has been reported only twice previously is left ventricular-coronary sinus fistula.v' Address for reprints: Nicholas P. Rossi, MD, Division of Cardiothoracic Surgery, University of Iowa Hospitals and Clinics, Iowa City, IA 52240.
Brief communications 6 3 7
Case report. A 63-year-old white man initially was admitted to another hospital in 1978 and underwent cardiac catheterization, which revealed severe mitral regurgitation. The patient underwent mitral valve replacement with a size 33 Angell-Shiley porcine valve in 1978 for a flail anterior mitral leaflet and a ruptured chorda. At the 3-month clinic visit a new systolic murmur was noted, which was believed to be mitral regurgitation. Because the patient was asymptomatic, he was observed. He experienced a small cerebrovascular accident in 1980 and was placed on a regimen of anticoagulation. He did well until 2 months before operation. At that time he noted increasing fatigue, dyspnea, and orthopnea. On admission he was noted to be in sinus rhythm with a grade 3/6 holosystolic murmur. Echocardiogram revealed a peak mitral gradient of 20 mm Hg, and the mitral valve area was estimated to be 1.0 cm-. The diameter of the left atrium was 4.6 ern. There was no significant mitral regurgitation. He underwent a graded exercise tolerance stress test, which revealed no abnormalities. Isotope ventriculogram revealed a left ventricular ejection fraction of 64%. Catheterization revealed a pulmonary artery pressure of 70/24 mm Hg, right ventricular pressure of 70/40 mm Hg, right atrial pressures of 12/10/8 mm Hg (a wave,v wave, mean), pulmonary capillary wedge pressures of 24/38/21 mm Hg (a wave, v wave, mean), and left ventricular end-diastolic pressure of 18 mm Hg. The mean mitral valve gradient was 8.2 mm Hg and the cardiac output was 4.14 L/min; the mitral valve area was calculated to be 2.3 em', Cardiac index was 2.0 L/min/m 2• No mitral regurgitation was noted and oxygen saturation step-up revealed a left-to-right shunt of 2.3:1. Left ventriculogram revealed normal wall motion in all segments. At operation the Angell-Shiley porcine valve was noted to have numerous fibrocalcific densities on the leaflets. There was good incorpo-
Fig. 1. Angiogram at catheterization demonstrated fistulous connection (F) between coronary sinus (eS) and left ventricle (LV).
The Journal of
638
Brief communications
ration of the sewing ring into the anulus with no perivalvular leaks. The Shiley valve was excised. Two fistulas were found posteromediaIly below the anulus and were separated from one another by approximately I cm. These fistulas were approximately 0.3 to 0.5 cm in diameter and communicated directly with the coronary sinus. Each was closed with pledgetsupported sutures. A size 31 Medtronic Hall valve was placed. The postoperative course was uncomplicated. Two months after the operation the patient was in New York Heart Association class I.
Discussion. There have been numerous reports of congenital coronary arteriovenous fistulas.v" Chambers and Rogers' reported a left ventricular--eoronary vein fistula after mitral valve replacement. However, this was attributed to the left ventricular stab wound made to introduce the left ventricular apical vent. Thorough debridement of the calcific anulus and operative injury to the mitral valve anulus have been reported to be associated with abnormal communication between the various heart structures." There have been two reported cases of left ventricular--eoronary sinus fistula.v' Each of these cases was associated with multiple mitral valve replacements. Miller and associates' postulated that the fistulas perhaps were related to operative injury with development of intramural or intraseptal dissection, which later ruptured into the coronary sinus. In that particular case the cause was indeed likely related to the development of intraseptal dissection with rupture into the coronary sinus. The current emphasis on preservation of the subvalvular mechanism will likely be helpful in preventing this complication in the future. Obviously with each operation the risk of operative trauma becomes greater. This case report is unique in that the complication occurred after the initial operation in which no technical difficulties were encountered. A soft systolic murmur was noted at 3 months. The patient, however, remained asymptomatic until 8 years later. From this observation it appears that as with many arteriovenous fistulas, the shunt slowly increased until there was cardiac decompensa-
Thoracic and Cardiovascular Surgery
tion. Technical considerations in closure of the fistula have been relatively simple. Miller and colleagues' reported closure through a right atriotomy with pledgetsupported suture of a rent approximately 1.5 em from the eustachian valve. Morritt and colleagues' were able to close the fistula with pledget-supported sutures through a left atriotomy after removal of the mitral prosthesis. We used the same technique. In review of this case we were unable to identify the specific etiologic factor responsible for this rare complication. This case, however, serves to reemphasize the great care needed in debridement of the mitral anulus and placement of the sutures to secure the mitral prosthesis. REFERENCES I. MacVaugh H III, Joyner CR, Johnson J. Unusual compli-
2.
3.
4.
5.
6.
7.
cations during mitral valve replacement in the presence of calcification of the annulus. Ann Thorac Surg 1971; 11:337-41. Marsten JL, Hildner FJ. Left ventricular-right atrial communication following valve replacement. J THORAC CARDIOVASC SURG 1969;58:588-91. Miller DC, Schapira IN, Stinson EB, Shumway NE. Left ventricular-coronary sinus fistula following repeated mitral valve replacements. J THORAC CARDIOVASC SURG 1978; 76:43-5. Morritt GN, Jamieson MPG, Irving JB, Marquis RM, Walbaum PRo Development of left ventricular-coronary sinus fistula following replacement of mitral valve prosthesis. J THORAC CARDIOVASC SURG 1978;76:381-4. Upshaw CB Jr. Congenital coronary arteriovenous fistula: report of a case with an analysis of seventy-three reported cases. Am Heart J 1962;63:399-404. Mantini E, Grondin CM, Lillehei CW, Edwards JE. Congenital anomalies involving the coronary sinus. Circulation 1966;33:317-27. Chambers RJ, Rogers MA. Left ventricular-to-coronary vein fistula following mitral valve replacement. Ann Thorae Surg 1972;14:305-8.
Left ventricular-coronary sinus fistula after mitral valve replacement Anthony G. Rogers, MD, and Nicholas P. Rossi, MD, Iowa City, Iowa From the Division of Cardiothoracic Surgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa.
One of the more rare complications after mitral valve replacement is the development of a left ventricular-eoronary sinus fistula, which has been reported only twice before. In the reported cases a common feature has been multiple valve replacements. Our case was one of the late development (8 years) of a fistula in a patient who had only one previous replacement but in whom a murmur was detected 3 months after the operation.
Mitral valve replacement has been associated with many complications, which include posterior left ventricular rupture, left ventricular-right atrial fistula, circumflex artery injury, and cardiac rhythm disturbances, among others. I. 2 A rare complication that to our knowledge has been reported only twice previously is left ventricular-coronary sinus fistula.v' Address for reprints: Nicholas P. Rossi, MD, Division of Cardiothoracic Surgery, University of Iowa Hospitals and Clinics, Iowa City, IA 52240.
Brief communications 6 3 7
Case report. A 63-year-old white man initially was admitted to another hospital in 1978 and underwent cardiac catheterization, which revealed severe mitral regurgitation. The patient underwent mitral valve replacement with a size 33 Angell-Shiley porcine valve in 1978 for a flail anterior mitral leaflet and a ruptured chorda. At the 3-month clinic visit a new systolic murmur was noted, which was believed to be mitral regurgitation. Because the patient was asymptomatic, he was observed. He experienced a small cerebrovascular accident in 1980 and was placed on a regimen of anticoagulation. He did well until 2 months before operation. At that time he noted increasing fatigue, dyspnea, and orthopnea. On admission he was noted to be in sinus rhythm with a grade 3/6 holosystolic murmur. Echocardiogram revealed a peak mitral gradient of 20 mm Hg, and the mitral valve area was estimated to be 1.0 cm-. The diameter of the left atrium was 4.6 ern. There was no significant mitral regurgitation. He underwent a graded exercise tolerance stress test, which revealed no abnormalities. Isotope ventriculogram revealed a left ventricular ejection fraction of 64%. Catheterization revealed a pulmonary artery pressure of 70/24 mm Hg, right ventricular pressure of 70/40 mm Hg, right atrial pressures of 12/10/8 mm Hg (a wave,v wave, mean), pulmonary capillary wedge pressures of 24/38/21 mm Hg (a wave, v wave, mean), and left ventricular end-diastolic pressure of 18 mm Hg. The mean mitral valve gradient was 8.2 mm Hg and the cardiac output was 4.14 L/min; the mitral valve area was calculated to be 2.3 em', Cardiac index was 2.0 L/min/m 2• No mitral regurgitation was noted and oxygen saturation step-up revealed a left-to-right shunt of 2.3:1. Left ventriculogram revealed normal wall motion in all segments. At operation the Angell-Shiley porcine valve was noted to have numerous fibrocalcific densities on the leaflets. There was good incorpo-
Fig. 1. Angiogram at catheterization demonstrated fistulous connection (F) between coronary sinus (eS) and left ventricle (LV).
The Journal of
638
Brief communications
ration of the sewing ring into the anulus with no perivalvular leaks. The Shiley valve was excised. Two fistulas were found posteromediaIly below the anulus and were separated from one another by approximately I cm. These fistulas were approximately 0.3 to 0.5 cm in diameter and communicated directly with the coronary sinus. Each was closed with pledgetsupported sutures. A size 31 Medtronic Hall valve was placed. The postoperative course was uncomplicated. Two months after the operation the patient was in New York Heart Association class I.
Discussion. There have been numerous reports of congenital coronary arteriovenous fistulas.v" Chambers and Rogers' reported a left ventricular--eoronary vein fistula after mitral valve replacement. However, this was attributed to the left ventricular stab wound made to introduce the left ventricular apical vent. Thorough debridement of the calcific anulus and operative injury to the mitral valve anulus have been reported to be associated with abnormal communication between the various heart structures." There have been two reported cases of left ventricular--eoronary sinus fistula.v' Each of these cases was associated with multiple mitral valve replacements. Miller and associates' postulated that the fistulas perhaps were related to operative injury with development of intramural or intraseptal dissection, which later ruptured into the coronary sinus. In that particular case the cause was indeed likely related to the development of intraseptal dissection with rupture into the coronary sinus. The current emphasis on preservation of the subvalvular mechanism will likely be helpful in preventing this complication in the future. Obviously with each operation the risk of operative trauma becomes greater. This case report is unique in that the complication occurred after the initial operation in which no technical difficulties were encountered. A soft systolic murmur was noted at 3 months. The patient, however, remained asymptomatic until 8 years later. From this observation it appears that as with many arteriovenous fistulas, the shunt slowly increased until there was cardiac decompensa-
Thoracic and Cardiovascular Surgery
tion. Technical considerations in closure of the fistula have been relatively simple. Miller and colleagues' reported closure through a right atriotomy with pledgetsupported suture of a rent approximately 1.5 em from the eustachian valve. Morritt and colleagues' were able to close the fistula with pledget-supported sutures through a left atriotomy after removal of the mitral prosthesis. We used the same technique. In review of this case we were unable to identify the specific etiologic factor responsible for this rare complication. This case, however, serves to reemphasize the great care needed in debridement of the mitral anulus and placement of the sutures to secure the mitral prosthesis. REFERENCES I. MacVaugh H III, Joyner CR, Johnson J. Unusual compli-
2.
3.
4.
5.
6.
7.
cations during mitral valve replacement in the presence of calcification of the annulus. Ann Thorac Surg 1971; 11:337-41. Marsten JL, Hildner FJ. Left ventricular-right atrial communication following valve replacement. J THORAC CARDIOVASC SURG 1969;58:588-91. Miller DC, Schapira IN, Stinson EB, Shumway NE. Left ventricular-coronary sinus fistula following repeated mitral valve replacements. J THORAC CARDIOVASC SURG 1978; 76:43-5. Morritt GN, Jamieson MPG, Irving JB, Marquis RM, Walbaum PRo Development of left ventricular-coronary sinus fistula following replacement of mitral valve prosthesis. J THORAC CARDIOVASC SURG 1978;76:381-4. Upshaw CB Jr. Congenital coronary arteriovenous fistula: report of a case with an analysis of seventy-three reported cases. Am Heart J 1962;63:399-404. Mantini E, Grondin CM, Lillehei CW, Edwards JE. Congenital anomalies involving the coronary sinus. Circulation 1966;33:317-27. Chambers RJ, Rogers MA. Left ventricular-to-coronary vein fistula following mitral valve replacement. Ann Thorae Surg 1972;14:305-8.