Severe Mitral Regurgitation Due to a “Folded” Anterior Mitral Valve Leaflet After Bentall Procedure Requiring Mitral Valve Replacement

Severe Mitral Regurgitation Due to a “Folded” Anterior Mitral Valve Leaflet After Bentall Procedure Requiring Mitral Valve Replacement

Journal of Cardiothoracic and Vascular Anesthesia ] (]]]]) ]]]–]]] Contents lists available at ScienceDirect journal homepage: www.jcvaonline.com C...

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Journal of Cardiothoracic and Vascular Anesthesia ] (]]]]) ]]]–]]]

Contents lists available at ScienceDirect

journal homepage: www.jcvaonline.com

Case Report

Severe Mitral Regurgitation Due to a “Folded” Anterior Mitral Valve Leaflet After Bentall Procedure Requiring Mitral Valve Replacement Jose R. Navas-Blanco, MDn,1, Stephanie A. Cook, DOn, Carlos Guerra-Londono, MDn, Jamil Borgi, MD†, Joseph A. Sanders, MD‡, Trevor J. Szymanski, MD‡ n

Department of Anesthesia, Pain Management and Perioperative Medicine, Henry Ford Hospital, Detroit, MI † Department of Surgery, Division of Cardiothoracic Surgery, Henry Ford Hospital, Detroit, MI ‡ Department of Anesthesia, Pain Management and Perioperative Medicine, Division of Cardiothoracic Anesthesia, Henry Ford Hospital, Detroit, MI

Keywords: severe mitral regurgitation; aortic valve replacement; aortomitral curtain; anterior mitral valve leaflet

THE AORTIC AND MITRAL valves share both anatomic and functional properties that may be altered during aortic valve (AV) surgery and effect concomitant mitral regurgitation (MR).1 The aortomitral curtain is the fibrous structure that connects the aortic and mitral valve annuli, making the 2 valves interdependent.2 Surgical aortic valve replacement (AVR) has been shown to alter the size and dynamics of the mitral valve annulus.3–5 Although MR may be expected to improve with isolated AVR and reduction of left ventricular systolic pressures, there is considerable variability in MR response when the etiology and severity of MR are considered.6,7 The authors report a case of a patient who underwent a Bentall procedure (composite AV and root replacement) for aortic stenosis, was found to have new severe MR after cardiopulmonary bypass (CPB), and ultimately required mitral valve replacement. Case Report A 67-year-old female with a history of hypertension, hyperlipidemia, and gastro-esophageal reflux disease presented 1

Address reprint requests to Jose R. Navas-Blanco, MD, Department of Anesthesia and Perioperative Medicine, Henry Ford Hospital, 2799 West Grand Boulevard, CFP-341, Detroit, MI 48202. E-mail address: [email protected] (J.R. Navas-Blanco).

to the authors’ institution for elective AVR for severe symptomatic aortic stenosis. Preoperative workup including cardiac catheterization and transthoracic echocardiogram documented nonobstructive coronary artery disease, preserved left ventricular function, AV peak and mean gradients of 76 mmHg and 43 mmHg, respectively, and no signs of mitral valve disease. Intraoperative transesophageal echocardiography (TEE) performed before CPB identified a bicuspid AV (annulus 17 mm  20 mm) with peak and mean gradients of 67 mmHg and 31 mmHg, respectively, an ascending aorta measuring 2.8 cm, and a normal appearing mitral valve with mild MR (Fig 1, Video Clip 1). During the procedure, it was noted that the aortic tissue was extremely thin on surgical inspection. The AV initially was replaced with a 21-mm Trifecta bioprosthesis (St. Jude Medical, St. Paul, MN) and seated in place using COR-KNOT sutures (LSI Solutions, Victor, NY). However, one of the COR-KNOT sutures resulted in a full thickness injury to the left coronary sinus, and an intraoperative decision was made to convert the procedure into a modified Bentall root replacement. A 26-mm synthetic aortic root graft (Gelweave, Vascutek, Glasgow, Scotland) with a 21-mm Mitroflow bioprosthetic AV (Sorin Biomedical, Milan, Italy) was assembled and placed, along with reimplantation of the coronary arteries. After separation from CPB, the TEE revealed new left ventricle (LV) inferior wall hypokinesis, significant edema of

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muscle tip by the aortic valve bioprosthesis. There was concern that with discontinuation of ECMO and increased LV volume, the tethering would worsen, and the MR would not improve. On postoperative day 5, the patient returned to the operating room and ultimately underwent mitral valve replacement with a 25-mm Carpentier-Edwards PERIMOUNT Magna Ease (Edwards Lifesciences, Irvine, CA). Intraoperative inspection by the surgeon confirmed elevation and folding of the AMVL. The patient was weaned from ECMO 4 days after MV replacement and was discharged to rehabilitation after a prolonged recovery. Discussion Fig 1. Pre–cardiopulmonary bypass transesophageal echocardiography midesophageal long-axis view illustrating a hypertrophied left ventricle, a thin anterior mitral valve leaflet (AMVL), AMVL length of 2.5 cm, a tenting height of 0.6 cm, and calcification of the aortic valve. Aortic valve annulus anterior– posterior diameter (minimum diameter) of 17 mm. Video Clip 1.

the aortomitral curtain, a thickened and tethered anterior mitral valve leaflet, and new onset severe MR (Fig 2, Video Clip 2). A coronary artery bypass graft was placed to the right coronary artery with the hope of improving the function of the inferior wall and possibly resolving the unexpected mitral regurgitation. There was no immediate improvement of the inferior wall motion abnormality or the MR, and the decision was made to place the patient on veno-arterial extracorporeal membrane oxygenation (ECMO) to support and rest the heart. On postoperative day 1, the patient returned to the operating room for mediastinal exploration and attempted to wean from ECMO. TEE examination revealed recovery of the LV inferior wall motion, normal LV function, an underfilled LV, and persistent severe MR. Further evaluation with 3-dimensional (3D) TEE revealed a band of tissue extending from the base to the tip of the anterior mitral valve leaflet (AMVL) and represented the AMVL folding on itself along the length of A2 (Fig 3, Video Clip 3). The folding was attributed to anatomical distortion related to the placement of sutures for AV replacement and/or tethering of the AMVL due to displacement of the mitral annulus away from the papillary

The aortomitral curtain is a fibrous continuity that connects the aortic and mitral annuli joining the anterior leaflet of the mitral valve and the noncoronary and left coronary leaflets of the aortic valve in the roof of the LV and contributes to the interdependency of these 2 valves.2 The aortic and mitral valve annuli contract, expand, and change shape throughout the cardiac cycle to facilitate left ventricular diastolic inflow and systolic outflow.4 In systole, the aortomitral curtain position shifts atrially, increasing the AV anterior–posterior diameter, creating a more circular AV annulus, and providing a larger cross-sectional area for LV ejection, while the MV annulus assumes its characteristic saddle shape.8–11 In diastole, the aortomitral curtain shifts toward the left ventricular outflow tract, the mitral annulus flattens, the MV annular area increases, and the AV annulus becomes more elliptical with a shorter AV anterior–posterior diameter to promote left ventricular filling and AV closure.4,8 Surgical AVR introduces a rigid circular ring at, or just above, the surgical annulus of the aortic valve. This rigid structure alters the normal dynamics of the aortomitral curtain. Mahmood et al demonstrated in a population of 35 patients who underwent surgical AVR a significant reduction in MV annulus area, annulus circumference, anterior annulus length, and inter-commissural diameter. These changes in mitral valve geometry were attributed to mechanical compression of the aortomitral curtain by the prosthetic valve.4 These findings are

Fig 2. Post–cardiopulmonary bypass transesophageal echocardiogram mid-esophageal long-axis view with and without color Doppler. The anterior mitral valve leaflet (AMVL) is thickened, the AMVL length is 2.2 cm, and the tenting height is 0.9 cm. There is significant edema of the aortomitral curtain and severe mitral regurgitation (vena contracta 6.7 mm). The 21-mm Mitroflow bioprosthetic aortic valve (outer diameter of 20.6 mm and a sewing ring of 24 mm) is seen in long axis. Video Clip 2. Please cite this article as: Navas-Blanco JR, et al. (2017), http://dx.doi.org/10.1053/j.jvca.2017.08.045

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Fig 3. Postoperative day 1 3D transesophageal echocardiography on extracorporeal membrane oxygenation. The mitral valve is rotated to the “surgeon’s view.” The left image depicts the valve in systole, and the right image depicts diastole. The yellow arrows point to a band of folded or bunched tissue extending from the base to the tip of the AMVL. Video Clip 3.

supported by Tsang et al, who found a significant decrease in the intercommissural diameter and mitral annular area after AVR.12 In the case presented, it was postulated that a geometrical alteration caused by the rigid bioprosthetic aortic valve produced a decrease in the length of the anterior MV annulus from compression of the aortomitral curtain and resulted in “bunching” or “folding” of the tissue that forms the base of the AMVL at the aortomitral curtain (Fig 3, Video Clip 3). A subsequent study by Warraich et al illustrated that surgical AVR was associated with a decreased systolic vertical annular displacement of the MV.5 This supports the assumption that a rigid ring in the aortic position creates a relatively fixed mitral annulus, preventing the normal increase in mitral valve height to a “saddle shape” during systole.3,5,12 The point at which the anterior mitral valve annulus and leaflet base becomes fixed is dependent on the size and insertion point of the AV prosthesis. Relative to the patient’s left ventricular outflow tract and aortic annulus, a smaller AV bioprothesis may decrease the MV annulus height, while a larger AV bioprosthesis may fix the anterior MV annulus further from the papillary muscle tips creating a potential for AMVL tethering.12 In the case reported, the aortic valve annulus minimum (anterior–posterior) and maximum diameters measured using 3D TEE were 17 mm and 20 mm, respectively. A 21-mm Mitroflow bioprosthesis (Sorin Biomedical, Milan, Italy), which has an outer diameter of 20.6 mm and a sewing ring width of 24 mm, was placed in the aortic position. This AV bioprosthesis could cause up to 4 to 7 mm displacement of the AMVL base from the preoperative measurement of 17 mm. This displacement, along with significant aortomitral curtain edema, could explain the postoperative tethering of the AMVL, which persisted even after recovery of LV function. Mitral regurgitation is encountered commonly in the setting of aortic stenosis as chronic pressure overload leads to left ventricular concentric hypertrophy, remodeling, and increased transmitral pressure gradients. With surgical AVR, decreased LV systolic pressures, and a reduction in mitral annulus area, one would expect mitral regurgitation to improve. However, a review of 17 studies with over 3,000 patients undergoing surgical AVR with coexisting MR showed improvement in

MR severity in only 55% of patients with worsening MR in almost 7%. Subgroup analysis showed more improvement among those with functional MR and moderate MR severity.1 New-onset severe MR after AVR is uncommon, and intraoperative TEE can be used to determine the mechanism and guide treatment. Case reports of new severe MR after AVR highlight the anatomic relationship between the 2 valves and include tear13 and perforation14 of the AMVL base, likely related to surgical valve placement. Additional case reports, including a new LV regional wall motion abnormality with AMVL tethering attributed to poor myocardial protection,15 and MV chordal injury from removal of an LV drain causing leaflet flail,16 illustrate alternative etiologies of severe MR involving the subvalvular apparatus. To the best of the authors’ knowledge, this is the first description and TEE illustration of “folded” or “elevated” anterior mitral valve leaflet tissue causing severe mitral regurgitation after composite aortic valve and root graft placement. This case highlights the aortomitral curtain as a critical link between the anatomy and function of the aortic and mitral valves and demonstrates the additional benefit of 3D with 2D imaging for evaluation of the mitral valve. Alterations of the normal aortomitral dynamics with placement of a rigid aortic valve bioprosthesis can affect mitral valve leaflet anatomy and subvalvular apparatus function. Appendix A. Supplementary material Supplementary data associated with this article can be found in the online version at http://dx.doi.org/10.1053/j.jvca.2017.08.045.

References 1 Harling L, Saso S, Jarral OA, et al. Aortic valve replacement for aortic stenosis in patients with concomitant mitral regurgitation: Should the mitral valve be dealt with? Eur J Cardiothorac Surg 2011;40:1087–96. 2 Van Mieghem NM, Piazza N, Anderson RH, et al. Anatomy of the mitral valvular complex and its implications for transcatheter interventions for mitral regurgitation. J Am Coll Cardiol 2010;56:617–26. 3 Vergnat M, Levack M, Jackson B, et al. The effect of surgical and transcatheter aortic valve replacement on mitral annular anatomy. Ann Thorac Surg 2013;95:614–9.

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4 Mahmood F, Warraich HJ, Gorman JH 3rd, et al. Changes in mitral annular geometry after aortic valve replacement: A three-dimensional transesophageal echocardiographic study. J Heart Valve Dis 2012;21: 696–701. 5 Warraich H, Matyal R, Bergman R, et al. Impact of aortic valve replacement for aortic stenosis on dynamic mitral annular motion and geometry. Am J Cardiol 2013;112:1445–9. 6 Unger P, Plein D, Van Camp G, et al. Effects of valve replacement for aortic stenosis on mitral regurgitation. Am J Cardiol 2008;102:1378–82. 7 Kaczorowski DJ, Macarthur JW, Howard J, et al. Quantitative evaluation of change in coexistent mitral regurgitation after aortic valve replacement. J Thorac Cardiovasc Surg 2013;145:341–7. discussion 347–8. 8 Hamdan A, Guetta V, Konen E, et al. Deformation dynamics and mechanical properties of the aortic annulus by 4-dimensional computed tomography: Insights into the functional anatomy of the aortic valve complex and implications for transcatheter aortic valve therapy. J Am Coll Cardiol 2012;59:119–27. 9 Grewal J, Suri R, Mankad S, et al. Mitral annular dynamics in myxomatous valve disease: New insights with real-time 3-dimensional echocardiography. Circulation 2010;121:1423–31.

10 Maslow A. Mitral valve repair: An echocardiographic review: Part 1. J Cardiothorac Vasc Anesth 2015;29:156–77. 11 Sucha D, Tuncay V, Prakken NH, et al. Does the aortic annulus undergo conformational change throughout the cardiac cycle? A systematic review. Eur Heart J Cardiovasc Imaging 2015;16:1307–17. 12 Tsang W, Veronesi F, Sugeng L, et al. Mitral valve dynamics in severe aortic stenosis before and after aortic valve replacement. J Am Soc Echocardiography 2013;26:606–14. 13 Islamoglu F, Apaydin AZ, Degirmenciler K, et al. Detachment of the mitral valve anterior leaflet as a complication of aortic valve replacement. Tex Heart Inst J 2006;33:54–6. 14 Maddali MM, Waje ND, Kandachar PS, et al. Rare cause of new mitral regurgitation after aortic valve replacement. J Cardiothorac Vasc Anesth 2016;30:845–7. 15 Essandoh M, Otey A, Bhandary S, et al. Severe mitral regurgitation complicating minimally invasive aortic valve replacement: Is it functional or organic? J Cardiothoracic Vasc Anesth 2015;29:1743–60. 16 Steiman J, Chaney M. Iatrogenic mitral valve injury during aortic valve replacement: Importance of intraoperative echocardiography. J Cardiothorac Vasc Anesth 2011;25:586.

Please cite this article as: Navas-Blanco JR, et al. (2017), http://dx.doi.org/10.1053/j.jvca.2017.08.045