Sir,
The mitral valve in adult patients with atrio-ventricular canal defect (AVCD) is often thickened or sclerotic, unsuitable for repair, and valve replacement may be the only option.[1] In such patients, the prosthetic leaflet mobility may be restricted by residual valve tissue,[2] subvalvular apparatus,[3] sutures taken for sewing ring,[4] or multiple sutures at proximity.
Our patient was a 28-year-old female (BSA 1.79 m2) with transitional AVCD scheduled for an ostium primum atrial septal defect (ASD) and inlet ventricular septal defect (VSD) closure and mitral valve replacement for severe regurgitation and leaflet sclerosis. Under general anesthesia, an adult transesophageal echocardiography (TEE) probe (Vivid E9, General Electrics, India) was inserted which confirmed the preoperative diagnosis. ASD pericardial patch and VSD direct closure were performed, and mitral valve replaced with 27 mm St Jude’s mechanical bileaflet prosthetic valve. After weaning from cardiopulmonary bypass (CPB), severe transvalvular regurgitation was identified on mid-esophageal four chamber TEE view. The 3D TEE mitral valve en face imaging showed restricted mobility of one of the mechanical leaflets [Video 1]. The left ventricle TEE view of the mitral valve revealed a suture used for VSD closure restricting the opening of the leaflet [Figure 1]. The CPB was recommenced, and the prosthetic valve was rotated and reimplanted in the mitral anatomical position [Video 2]. After this the patient was uneventfully weaned off CPB. The TEE showed normal prosthetic valve motion and 7/3 mmHg (peak/mean) gradients across the valve.
Figure 1.
The 3D transesophageal echocardiography mitral valve left ventricle view showing a suture taken for ventricle septal defect closure restricting motion of prosthetic mitral leaflet. (VSD: ventricle septal defect)
In this case we believe the sutures taken for the inlet VSD closure restricted the leaflet movement. This was detected on the 3D TEE after CPB. Placement of the prosthesis in anatomical position was helpful in our patient.
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Conflicts of interest
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