DOI: 10.1111/jocs.13198

SURGICAL TECHNIQUE

Third time mitral valve replacement-lessons learned Haytham Elgharably MD Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio Correspondence G. B. Pettersson MD, PhD, Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, 9500 Euclid Avenue/Desk J4-1, Cleveland, OH Email: [email protected]

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Faisal G. Bakaeen MD | Gösta B. Pettersson MD, PhD

Abstract We report the management of three iatrogenic injuries involving the aortic valve, left circumflex artery, and left ventricular outflow tract, that occurred during a re-operative mitral valve replacement.

1 | INTRODUCTION

atrial fibrillation, Pseudomonas pneumonia, clostridium difficile colitis, thrombocytopenia, and gastrointestinal bleeding.

Mitral valve replacement may result in unique iatrogenic compli1,2

She was transferred to our institute in congestive heart failure that

These risks are increased during re-operative proce-

was presumed to be secondary to AI. A transthoracic echocardiogram

dures. Repeat mitral valve replacements may compromise the

showed an ejection fraction of 43%, severe hypokinesia of the inferior

annulus and increase the risk for iatrogenic injury of surrounding

and posterior walls, pulmonary hypertension (69 mmHg), severe AI

anatomical structures. In this report, we present a case of

(anteriorly directed regurgitant jet against the septum), mild mitral

iatrogenic acute aortic insufficiency, injury to the left circumflex

regurgitation,

coronary artery (LCX), and left ventricular (LV) outflow tract

(Figure 1A and 1B). A transcatheter aortic valve replacement was

(LVOT) obstruction complicating a redo mitral valve replacement

considered but felt not to be technically possible because of deficient

which required a third time mitral valve replacement. While each of

aortic annular calcification on a cardiac computed tomography (CT)

the complications is well described during mitral valve surgery,

scan. The CT scan showed protrusion of one of the mitral valve

addressing three concomitant complications is unique and serves

bioprosthetic struts in the LVOT (Figure 2). Cardiac catheterization

as reminder of the multiple pitfalls associated with re-operative

showed a new 80% narrowing of the LCX artery in the proximity of the

mitral valve operations.

mitral annulus (Figure 3).

1.1 | Patient profile

1.2 | Surgical technique

This case was exempted from Institutional Review Board approval as it

It was decided to proceed with a third time re-operation. An intra-

presents de-identified patient information for educational purposes. A

operative trans-esophageal echocardiogram showed moderate LV

65-year-old female with history of rheumatic mitral valve disease and

systolic dysfunction and severe AI from an eccentric regurgitant jet at

two previous mitral valve surgeries, commissurotomy and mitral valve

the left aortic cusp (Figure 1C and D). She underwent a redo-sternotomy

replacement (MVR) presented with a degenerated mitral biopros-

and aorto-bicaval cannulation. Antegrade and direct retrograde

thesis. Co-morbidities included hypertension, diabetes mellitus, and a

cardioplegia were given. A proximal aortotomy showed a large

history of stroke. She underwent a second-time redo MVR with a new

perforation at the bottom of the left cusp, which was entrapped by a

bioprosthesis (31 mm PERIMOUNT Magna Mitral Ease, Edwards

mitral valve suture. The mitral bioprosthesis was malrotated with one of

Lifesciences, Irvine, CA). Post-operatively, she failed weaning from the

the struts in the middle of the LVOT. The mitral valve was approached

ventilator for 2 months due to recurrent pulmonary edema and

next through the atrial septum. The old mitral bioprosthesis was

required a tracheostomy. She also developed renal failure requiring

removed and the mitral annulus was carefully debrided, removing all old

hemodialysis. Repeated echocardiograms demonstrated new moder-

suture material. Next, before implanting a new mitral valve prosthesis a

ate aortic insufficiency (AI). Other complications included new onset of

vein graft was placed to the posterolateral branch of the LCX artery.

cations.

J Card Surg. 2017;1–3.

wileyonlinelibrary.com/journal/jocs

and

mild

to

moderate

tricuspid

regurgitation

© 2017 Wiley Periodicals, Inc.

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ELGHARABLY

ET AL.

FIGURE 1 Pre-operative transthoracic (A and B) and intra-operative transesophageal (C and D) echocardiographic images showing eccentric aortic regurgitant jet. Aortic valve long axis views (A and C). Aortic valve short axis views (B and D)

Mitral valve sutures were placed. Since there was no residual

Her recovery has been slow and the post-operative course was

intervalvular fibrosa underneath the aortic valve, a bovine pericardial

complicated by fungemia (Candida glabrata) and a relapse of Pseudomo-

patch was used for intervalvular fibrosa reconstruction. A Biocor

nas pneumonia. She was weaned off the ventilator after 6 weeks with

31- mm mitral bioprosthesis (St. Jude Medical, Inc., St. Paul, MN) was

supplemental oxygen therapy through her capped tracheostomy. She

inserted followed by an aortic valve replacement with a Trifecta 21- mm

developed post-operative delirium early after surgery that resolved and

bioprosthesis (St. Jude Medical, Inc.). A proximal vein graft anastomosis

was fully oriented at the time of discharge. She was discharged to a long-

to the ascending aorta was then performed. Total cardiopulmonary

term chronic care facility for further recovery while on intermittent

bypass time was 160 min and total aortic cross clamp time was 145 min.

hemodialysis and with extended course of antimicrobial therapy

The patient was weaned off cardiopulmonary bypass with good

(cefotolozane/tazobactam and micafungin). She was readmitted to the

hemodynamics on low doses of inotropic support. A post-pump echocardiogram showed well-seated aortic and mitral bioprostheses and slightly improved LV function (ejection fraction 45%).

FIGURE 2 CT scan showing strut of mitral bioprosthesis projecting into the LVOT. Ao, ascending aorta; Bio-MV, bioprosthetic mitral valve; CT, computed tomography; LV, left ventricle

FIGURE 3 Coronary angiogram of the left system showing mid hazy lesion of the left circumflex coronary artery in close proximity to the mitral bioprosthesis

ELGHARABLY

ET AL.

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3

hospital with positive blood cultures (Enterococcus faecium) secondary to

performing a small aortotomy to verify that the bioprosthetic mitral valve

a dialysis catheter infection. A repeat echocardiogram showed vegeta-

struts have not resulted in an LVOT obstruction may help to avoid the

tions on the mitral valve prosthesis but no valve dysfunction. The patient is

need for another re-operation.

hemodynamically stable, afebrile with no signs of sepsis, and clinically

In complicated re-operative procedures, a pre-operative echocar-

improving. To treat and suppress probable prosthetic valve endocarditis,

diogram, CT scan of the chest, and coronary angiogram are essential to

antimicrobial therapy was changed to ampicillin, and renal adjusted dose

accurately depict the anatomy and the lesions that must be repaired or

of indefinite fluconazole. Her repeat blood cultures are negative.

replaced.11 Having allow index of suspicion for surgical complications

Currently, she is 4 months out of her last surgery and discharged to a

after redo procedures, and making the diagnosis and intervene early

long-term facility after a three weeks second hospitalization at out

can prevent an unfavorable clinical outcome.

institute. CONFLICTS OF INTEREST

2 | C OMM E NT S

Authors have no conflicts of interest.

The mitral annulus has been described as a tissue plane at the

ORCID

confluence of surrounding structures rather than a distinctive anatomical entity.3 Injuries to the adjacent structures such as the

Haytham Elgharably

http://orcid.org/0000-0002-8124-0123

aortic valve or LCX artery are well-documented complications during MVR.4,5 Similarly, the potential for LVOT obstruction by a bioprosthesis strut in the mitral position has been described.6 The risk for surgical complications is higher with an increasing number of repeated surgeries on the mitral valve. Removal of the prosthesis and debridement of the annulus of old surgical materials, pannus, calcification, or fibrosis leaves an undermined annulus for the placement of new prosthesis sutures. Gosev et al7 reported a case of repeated prosthetic valve dehiscence and nearly absent mitral annulus after three MVR procedures precluding implanting a new prosthetic valve and requiring biventricular mechanical support as a bridge to heart transplantation. Conversly, insufficient debridement may compromise sizing or seating of the new prosthesis, increasing the risk for malfunction and paravalvular leakage. The optimal conduct of a MVR re-operation requires adequate debridement with the possibility of annular reconstruction. In addition to patient co-morbidities, nature of the procedure, number of prior operations, and reentry adverse events,8,9 the outcomes of redo valve surgery are also dependent on perfusion strategy, myocardial protection, hemostasis, and the experience of the surgical teams.9,10 Ideal exposure is more difficult to obtain during redo mitral valve surgery. To optimize mitral valve exposure in the redo setting, the LV apex needs to be freed or in case of extensive pericardial adhesions, the left pleural space is opened. The trans-septal approach to the mitral valve is easy to extend to the dome of the left atrium if needed. An aortotomy gives additional access to the mitral annulus and defines the mitral annulus relation to the aortic valve, and facilitates debridement of the annulus as

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well as placement of the valve sutures. In the setting of double valve replacement, our threshold to approach the mitral valve from the aortic side and the dome of the left atrium is low. Appreciation of the anatomical

How to cite this article: Elgharably H, Bakaeen FG,

relationships and understanding the underlying pathology are essential to

Pettersson GB. Third time mitral valve replacement-lessons

avoid iatrogenic injuries to the surrounding structures. Proper sizing and

learned. J Card Surg. 2017;1–3.

orientation of the mitral prosthesis is a safeguard against LVOT

https://doi.org/10.1111/jocs.13198

obstruction. Even when an AVR is not necessary during a re-operation,