Diagnosis
by Transesophageal Echocardiography of Atrioventricular Dissection After Mitral Valve Replacement
Groove
Richard Lingreen, MD, Mark Eaton, MD, Demetrios G. Lappas, MD, and Benico Barzilai, MD
L
EFT VENTRICULAR
(LV) wal1 rupture is an infrequent but potentially lethal complication after mitral valve replacement,’ and early diagnosis is essential for successful repair of the defect. Intraoperative transesophageal echocardiography (TEE) has proven to be a valuable tool for evaluation of valvular function and intraoperative monitoring. The following is a report of a patient in whom LV rupture was diagnosed intraoperatively with the use of TEE. CASE REPORT
The patient was an 81-year-old woman who was previously well, with no history of cardiovascular disease until 1 week before admission, when she noted fatigue and dyspnea on exertion. She denied chest pain, orthopnea, paroxysmal nocturnal dyspnea, or pedal edema at that time, and she presented to the hospita1 with new-onset atria1 fibrillation with a rapid ventricular response and extreme dyspnea. Physical examination at that time showed a normal blood pressure with an irregular pulse rate of 150 beatsi min. Examination of the heart showed a grade III/VI systolic murmur heard best at the apex with radiation to the axilla, and examination of the chest showed bibasilar crackles. Tests for elevated levels of creatine kinase and other isoenzymes were negative. Furosemide, digoxin, and quinidine were prescribed and she was transferred to this facility for further evaluation. Transthoracic echocardiography was performed and showed marked prolapse of the media1 segment of the posterior leaflet of the mitral valve, as wel1 as thickening of its anterior and posterior leaflets. On Doppler examination, severe mitral insufficiency without evidente of mitral valve stenosis was noted. The LV was moderately enlarged, with global function at the lower limits of normal. There were no regional wal1 motion abnormalities. LV function was
normal at cardiac catheterization,
with no evidente of fìxed
obstructive coronary artery disease. The decision was made to either repair or replace the mitral valve. In the operating room, intravascular catheters were inserted to monitor systemic and pulmonary arterial pressures and to measure cardiac output. The electrocardiogram (ECG) showed atria1 fibrillation with a slow ventricular response rate. A TEE probe was placed after induction of anesthesia to further characterize the mitral valve pathology (Fig 1). As in the transthoracic study, TEE demonstrated normal LV function and wal1 motion. Marked prolapse of the posterior leaflet of the mitral valve consistent with a fail leaflet was again noted, as was severe mitral regurgitation (the latter on color-flow Doppler examination). After median sternotomy and uncomplicated cannulation of the aorta and the vena cava, cardiopulmonary bypass (CPB) was instituted. The left atrium was opened and the valve was inspected, showing severe myxomatous degeneration of both the anterior and posterior leaflets. There were ruptured chordae on both the media1 and lateral aspects of the posterior leaflet. The anterior leaflet was thickened, but the chordal apparatus was intact. Because of the involvement of both leaflets, the surgeon elected not to attempt valve repair. Instead, the posterior leaflet was excised, and a no. 33 Carpentier-Edwards prosthesis (Minneapolis, MN) was placed without complication. The aortic cross-clamp was removed and the patient was rewarmed systemically to 37°C. The CPB flow was reduced to 2 Wmin with the generation of systemic pressures of 75 to 80 mm Hg. This was followed by a relatively sudden drop in arterial pressure, despite inotropic support. TEE at that time showed severe global LV hypokinesis. The porcine mitral valve appeared to be well-seated. However, an enlarging echo-dense mass in the posterolateral wal1 of the LV and left atrium was noted (Fig 2). Direct inspection of the atrioventricular groove showed an epicardial hematoma judged to be secondary to LV rupture. CPB was promptly reinstituted, the left atriotomy was reopened, and the valve was excised. There was an area of separation in the middle of the annulus between the atria1 and ventricular portion. This separation was patched and the valve was reinserted. The patient was rewarmed systemically, but it was not possible to wean her from CPB despite administration of high doses of inotropic agents. DISCUSSION
Rupture of the LV after mitral valve replacement is an infrequent but lethal complication. Combined data from 10 institutions in a recent review cited 60 cases of LV rupture during 4,979 valve replacements, for an incidence of 1.2%.’ LV rupture has been classified anatomically into three types: type 1 refers to a defect in the posterior atrioventricular groove; type 11 is located in the midportion of the LV at the base of the papillary muscle; and type 111occurs on the posterior wal1 of the LV between the base of the papillary
Fig 1. Long-axis echocardiogram of the patient showing posterior leaflet prolapse of the mitral valve with enterior and posterior leaflet thickening. LA, left atrium; LV, left ventricle; pl. posterior leaflet.
Journalof Cardiothoracic and VascularAnesthesia,
From the Departments ofAnesthesiology and Cardiology, Washington University Medical Center, St Louis, MO. Address reprint requests to Demettios C. Lappas, MD, Department of Anesthesiology, Washington University Medical Center, 660 S Euclid, Box 8054, St Louis, MO 63110. Copyright o 1991 by W. B. Saunders Company 1053-0770/91/0501-0013$03.00/0
Vol 5,NO 1 (February), 1991:pp 61-62
61
LINGREEN ET AL
In a previous publication, Kyo ct al’ reported a postoperative posterior LV wal1 motion abnormality that was evident on TEE and was associated with type 111 ventricular rupture. There have also been reports of early detection of LV rupture as an echo-dense mass in the pericardial spacc on the transthoracic echocardiogram.’ Intraoperative TEE enabled the identification of an echo-dense mass within the wal1 of the LV at the posterior atrioventricular groove. This represented a type 1 LV rupture with extension in the free wal1 of the LV. Despite early identification of the lesion before the onset of massive bleeding, the complication proved fatal. However, it demonstrates that TEE provides valuable information intraoperatively, and may enable physicians to detect LV rupture early enough so that CPB may be reinstituted and the lesion successfully repaired. REFERENCES Fig 2. Echocardiogram of patient showing replaced mitral vake with atrioventricular hematoma as echo-dense mass. Por, porcine mitral vake; Hem, hematoma.
and the atrioventricular groeve.’ It is not always possible to locate the site of the initial lesion, intraoperatively, secondary to extension of the rupture. In this patient, with the use of a 5-MHz TEE transducer, early identification of a type 1 rupture was made during discontinuation of cardiopulmonary bypass. To the authors’ knowledge, this is the first report of early LV rupture diagnosed intraoperatively by the use of TEE.
muscle
Karbon KJ, Ashraf
MM, Berger RL: Rupture of the left ventricle following mitral valve replacement. Ann Thorac Surg 46:590-597, 1988 2. Azariades M, Lennos S: Rupture of the posterior wal1 of the left ventricle after mitral valve replacement: Etiological and technical considerations. Ann Thorac Stug 46:491-494, 1988 3. Kyo SK, Takamoto S, Matsumura M, et al: Immediate and early postoperative evaluation of results of cardiac surgery by transesophageal two-dimensional Doppler echocardiography. Circulation 76:113-121, 1987 (suppl V) 4. Ennix CL, Ecker RR, Iverson LI, et al: Early detection and management of left ventricular free wal1 rupture during acute myocardial infarction. Am J Cardiol63:1.51-152, 1989 1.
by Transesophageal Echocardiography of Atrioventricular Dissection After Mitral Valve Replacement
Groove
Richard Lingreen, MD, Mark Eaton, MD, Demetrios G. Lappas, MD, and Benico Barzilai, MD
L
EFT VENTRICULAR
(LV) wal1 rupture is an infrequent but potentially lethal complication after mitral valve replacement,’ and early diagnosis is essential for successful repair of the defect. Intraoperative transesophageal echocardiography (TEE) has proven to be a valuable tool for evaluation of valvular function and intraoperative monitoring. The following is a report of a patient in whom LV rupture was diagnosed intraoperatively with the use of TEE. CASE REPORT
The patient was an 81-year-old woman who was previously well, with no history of cardiovascular disease until 1 week before admission, when she noted fatigue and dyspnea on exertion. She denied chest pain, orthopnea, paroxysmal nocturnal dyspnea, or pedal edema at that time, and she presented to the hospita1 with new-onset atria1 fibrillation with a rapid ventricular response and extreme dyspnea. Physical examination at that time showed a normal blood pressure with an irregular pulse rate of 150 beatsi min. Examination of the heart showed a grade III/VI systolic murmur heard best at the apex with radiation to the axilla, and examination of the chest showed bibasilar crackles. Tests for elevated levels of creatine kinase and other isoenzymes were negative. Furosemide, digoxin, and quinidine were prescribed and she was transferred to this facility for further evaluation. Transthoracic echocardiography was performed and showed marked prolapse of the media1 segment of the posterior leaflet of the mitral valve, as wel1 as thickening of its anterior and posterior leaflets. On Doppler examination, severe mitral insufficiency without evidente of mitral valve stenosis was noted. The LV was moderately enlarged, with global function at the lower limits of normal. There were no regional wal1 motion abnormalities. LV function was
normal at cardiac catheterization,
with no evidente of fìxed
obstructive coronary artery disease. The decision was made to either repair or replace the mitral valve. In the operating room, intravascular catheters were inserted to monitor systemic and pulmonary arterial pressures and to measure cardiac output. The electrocardiogram (ECG) showed atria1 fibrillation with a slow ventricular response rate. A TEE probe was placed after induction of anesthesia to further characterize the mitral valve pathology (Fig 1). As in the transthoracic study, TEE demonstrated normal LV function and wal1 motion. Marked prolapse of the posterior leaflet of the mitral valve consistent with a fail leaflet was again noted, as was severe mitral regurgitation (the latter on color-flow Doppler examination). After median sternotomy and uncomplicated cannulation of the aorta and the vena cava, cardiopulmonary bypass (CPB) was instituted. The left atrium was opened and the valve was inspected, showing severe myxomatous degeneration of both the anterior and posterior leaflets. There were ruptured chordae on both the media1 and lateral aspects of the posterior leaflet. The anterior leaflet was thickened, but the chordal apparatus was intact. Because of the involvement of both leaflets, the surgeon elected not to attempt valve repair. Instead, the posterior leaflet was excised, and a no. 33 Carpentier-Edwards prosthesis (Minneapolis, MN) was placed without complication. The aortic cross-clamp was removed and the patient was rewarmed systemically to 37°C. The CPB flow was reduced to 2 Wmin with the generation of systemic pressures of 75 to 80 mm Hg. This was followed by a relatively sudden drop in arterial pressure, despite inotropic support. TEE at that time showed severe global LV hypokinesis. The porcine mitral valve appeared to be well-seated. However, an enlarging echo-dense mass in the posterolateral wal1 of the LV and left atrium was noted (Fig 2). Direct inspection of the atrioventricular groove showed an epicardial hematoma judged to be secondary to LV rupture. CPB was promptly reinstituted, the left atriotomy was reopened, and the valve was excised. There was an area of separation in the middle of the annulus between the atria1 and ventricular portion. This separation was patched and the valve was reinserted. The patient was rewarmed systemically, but it was not possible to wean her from CPB despite administration of high doses of inotropic agents. DISCUSSION
Rupture of the LV after mitral valve replacement is an infrequent but lethal complication. Combined data from 10 institutions in a recent review cited 60 cases of LV rupture during 4,979 valve replacements, for an incidence of 1.2%.’ LV rupture has been classified anatomically into three types: type 1 refers to a defect in the posterior atrioventricular groove; type 11 is located in the midportion of the LV at the base of the papillary muscle; and type 111occurs on the posterior wal1 of the LV between the base of the papillary
Fig 1. Long-axis echocardiogram of the patient showing posterior leaflet prolapse of the mitral valve with enterior and posterior leaflet thickening. LA, left atrium; LV, left ventricle; pl. posterior leaflet.
Journalof Cardiothoracic and VascularAnesthesia,
From the Departments ofAnesthesiology and Cardiology, Washington University Medical Center, St Louis, MO. Address reprint requests to Demettios C. Lappas, MD, Department of Anesthesiology, Washington University Medical Center, 660 S Euclid, Box 8054, St Louis, MO 63110. Copyright o 1991 by W. B. Saunders Company 1053-0770/91/0501-0013$03.00/0
Vol 5,NO 1 (February), 1991:pp 61-62
61
LINGREEN ET AL
In a previous publication, Kyo ct al’ reported a postoperative posterior LV wal1 motion abnormality that was evident on TEE and was associated with type 111 ventricular rupture. There have also been reports of early detection of LV rupture as an echo-dense mass in the pericardial spacc on the transthoracic echocardiogram.’ Intraoperative TEE enabled the identification of an echo-dense mass within the wal1 of the LV at the posterior atrioventricular groove. This represented a type 1 LV rupture with extension in the free wal1 of the LV. Despite early identification of the lesion before the onset of massive bleeding, the complication proved fatal. However, it demonstrates that TEE provides valuable information intraoperatively, and may enable physicians to detect LV rupture early enough so that CPB may be reinstituted and the lesion successfully repaired. REFERENCES Fig 2. Echocardiogram of patient showing replaced mitral vake with atrioventricular hematoma as echo-dense mass. Por, porcine mitral vake; Hem, hematoma.
and the atrioventricular groeve.’ It is not always possible to locate the site of the initial lesion, intraoperatively, secondary to extension of the rupture. In this patient, with the use of a 5-MHz TEE transducer, early identification of a type 1 rupture was made during discontinuation of cardiopulmonary bypass. To the authors’ knowledge, this is the first report of early LV rupture diagnosed intraoperatively by the use of TEE.
muscle
Karbon KJ, Ashraf
MM, Berger RL: Rupture of the left ventricle following mitral valve replacement. Ann Thorac Surg 46:590-597, 1988 2. Azariades M, Lennos S: Rupture of the posterior wal1 of the left ventricle after mitral valve replacement: Etiological and technical considerations. Ann Thorac Stug 46:491-494, 1988 3. Kyo SK, Takamoto S, Matsumura M, et al: Immediate and early postoperative evaluation of results of cardiac surgery by transesophageal two-dimensional Doppler echocardiography. Circulation 76:113-121, 1987 (suppl V) 4. Ennix CL, Ecker RR, Iverson LI, et al: Early detection and management of left ventricular free wal1 rupture during acute myocardial infarction. Am J Cardiol63:1.51-152, 1989 1.
