Abstract
Rupture of the atrioventricular groove is an uncommon but dreaded complication of mitral valve replacement. We present the case of a 74-year-old male submitted to mitral valve surgery, complicated by atrioventricular groove rupture presaged by the excessive rocking movement of the prosthesis seen in the pre-discharge transthoracic echocardiogram.
<Learning objective: Valvular prosthesis rocking movement has been typically associated with paravalvular leaks and fistulae. To the best of our knowledge, this is the first case to illustrate the association of excessive rocking movement with atrioventricular groove weakness, anticipating subsequent sulcus rupture and pseudoaneurysm formation.>
Keywords: Atrioventricular groove rupture, Mitral prosthesis, Cardiac imaging
Case report
A 74-year-old male was referred for mitral valve (MV) surgery because of severe symptomatic mitral regurgitation (MR), caused by annulus dilation and posterior valve restriction (combination of Carpentier's type I and III mechanisms). Left ventricle (LV) was moderately dilated: LV end-diastolic dimension – 59 mm, LV ejection fraction (EF) – 66%.
MV annuloplasty with a Carpentier-Edwards® Physio ring nr 32 (Edwards Lifesciences, Irvine, CA, USA) was substandard: intraoperative transesophageal echocardiogram (TEE) showed greater than 2 MR, due to excessive tenting. MV replacement appeared to be the best solution. The ring was removed and a bioprosthesis was implanted. The anterior leaflet of the MV was severed 3 mm away from the annulus and its chordae were cut at their insertion to the papillary muscles. The posterior leaflet and its subvalvular apparatus were left intact. The Carpentier-Edwards® sizer nr 31 fitted nicely and the bioprosthesis (CarpentierSAV® 31) was implanted in intra-annular position. Eighteen Teflon-buttressed everted U-shaped Ethibond 00 stitches were used (Teflon pledgets on the atrial side). The stitches on the posterior part of the annulus folded the remaining leaflet prior to being secured to the prosthesis. No abnormal leak or prosthesis rocking was observed by intraoperative TEE (Videos 1 and 2).
On pre-discharge transthoracic echocardiogram (TTE) moderate compromise of LV function (EF – 35%) and right ventricular dysfunction were noticed (tricuspid annular plane systolic excursion – 15 mm). Mitral prosthesis Doppler parameters were fairly normal (median gradient 7 mmHg, functional area 2.1 cm2). There was no evidence of paravalvular leak, but an unusual rocking movement of the prosthesis caught our attention (Videos 3.1–3.3). Although this finding was of concern, the absence of heart failure symptoms, infection markers (the patient presented sustained apyrexia and no significant elevation of white blood cells and C-reactive protein), hemodynamic deterioration (blood pressure and heart rate at discharge were 108/76 mmHg and 80 bpm, respectively), or major laboratory anomalies (at discharge: hemoglobin 10.2 g/dL, white blood cells 7.23 × 109/L, C-reactive protein 11.9 mg/L, international normalized ratio 2.15) led us to decide for outpatient care.
On re-evaluation one month later, the patient complained of progressive dyspnea. TTE revealed rupture of posterior atrioventricular groove with pseudoaneurysm formation (Fig. 1; Video 4) and severe systolic biventricular dysfunction. Pseudoaneurysm dimensions (32 mm × 25 mm × 44 mm) and the entrance orifice area (0.33 cm2) were sized by three-dimensional (3D) TTE (Fig. 2). Cardiac magnetic resonance confirmed the 3D anatomical features and disclosed a close relation of the pseudoaneurysm and the left circumflex artery (Fig. 3; Video 5).
Fig. 1.
Two-dimensional color transthoracic echocardiogram showing left ventricular pseudoaneurysm (*). LV, left ventricle.
Fig. 2.
Three-dimensional transthoracic echocardiogram measurement of pseudoaneurysm (*). LV, left ventricle.
Fig. 3.
Cardiac magnetic resonance image, coronal view, showing pseudoaneurysm (*) and its relation with left circumflex artery (arrow). LV, left ventricle.
The exceedingly high mortality risk of a redo surgery favored the therapeutic decision toward a less invasive approach. Percutaneous closure was planned but heart failure rapidly evolved and the patient died soon after.
Discussion
Left ventricular rupture after MV replacement (MVR) was first described in 1967 by Roberts and Morrow. Occurring in 0.02–7.5% of MVR 1, 2, 3, 4, 5, 6 this complication is associated with a high mortality rate (up to 45%) 1, 2, 3.
According to location there are three types of rupture of the LV: at the atrioventricular groove (type I), at the posterior ventricular wall at the base of papillary muscles (type II), and at the posterior wall between the atrioventricular groove and the base of the papillary muscles (type III) [1]. Based on time of rupture onset it can be classified as in early rupture (taking place in the operating room), delayed rupture (occurring in hours to days), and late rupture (occurring days to years after MVR and presenting as a pseudoaneurysm) 1, 3, 6. Rupture in two stages, in which there is a normal echocardiogram after MVR and subsequent development of pseudoaneurysm, is infrequent, with only a few cases reported in the literature [2].
Different causes and mechanisms were incriminated. During surgery excessive decalcification of mitral annulus, resection of posterior leaflet and chordae, the use of high profile or too large prosthesis, previous MVR, and improper inspection of the posterior wall using the atrioventricular groove as a fulcrum were considered risk factors for the occurrence of ventricular rupture 3, 5, 6, 7. In addition, intraoperative or early postoperative hypertension, preexisting intrinsic myocardial disease (namely ischemic, rheumatic, and infectious processes), older age, female gender, hemodialysis, and small ventricular cavities have also been implicated 5, 6, 8. On the contrary, the coexistence of aortic valve stenosis is considered to confer protective effects, possibly because the resulting hypertrophied and thickened myocardium is more resistant to tearing [8]. In our case, the patient's age and the excessive manipulation of the groove attempting valve preservation could explain the atrioventricular sulcus weakness, with subsequent rupture.
Patients with LV pseudoaneurysm may be asymptomatic or present with progressive heart failure, ventricular arrhythmias, and symptoms resulting from the compression of extra-cardiac structures (as chest pain from left circumflex coronary artery compression). Also, there is a risk of rupture (which could be as high as 45%) and risk of embolization of thrombotic material from the cavity 2, 3.
Surgical treatment, with or without a bypass grafting to left circumflex artery, is the first-line therapy and several different techniques have been described. More recently, percutaneous closure has been used 4, 9, 10 as an alternative to surgery, particularly in high-risk patients. This can be accomplished using either endovascular coils 4, 10 or occluder device 9, 10. The therapeutic option depends essentially on the size of the aneurysm, width of the neck, location, and anatomic relationship with epicardial and endocardial structures [10].
Whatever the therapeutic approach, multimodality cardiac imaging is of the utmost importance in proper anatomic delineation, clearly defining the type and dimensions of LV, its relations to adjacent structures, and thereby allowing careful planning of the therapeutic strategy.
Conflict of interest
None declared.
Footnotes
Supplementary data associated with this article can be found, in the online version, at http://dx.doi.org/10.1016/j.jccase.2014.09.004.
Appendix A. Supplementary data
The following are the supplementary data to this article:
Intraoperative 2D colour transesophageal echocardiogram, 4-chamber view. Note the absence of abnormal leak or prosthesis rocking movement.
Intra-operative 2D colour transesophageal echocardiogram, 2-chamber view. Note the absence of abnormal leak or prosthesis rocking movement.
Pre-discharge 2D colour transthoracic echocardiogram, parasternal long-axis, apical 2-chamber view, apical 4-chamber view, respectively, showing excessive rocking movement of mitral prosthesis, but no evident paravalvular leak.
2D colour transthoracic echocardiogram, apical 2-chamber view, showing rupture of atrioventricular groove, with pseudoaneurysm formation.
Cardiac magnetic resonance imaging cine-loops, vertical long view, revealing a close relation of the pseudoaneurysm and the left circumflex artery.
References
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Associated Data
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Supplementary Materials
Intraoperative 2D colour transesophageal echocardiogram, 4-chamber view. Note the absence of abnormal leak or prosthesis rocking movement.
Intra-operative 2D colour transesophageal echocardiogram, 2-chamber view. Note the absence of abnormal leak or prosthesis rocking movement.
Pre-discharge 2D colour transthoracic echocardiogram, parasternal long-axis, apical 2-chamber view, apical 4-chamber view, respectively, showing excessive rocking movement of mitral prosthesis, but no evident paravalvular leak.
2D colour transthoracic echocardiogram, apical 2-chamber view, showing rupture of atrioventricular groove, with pseudoaneurysm formation.
Cardiac magnetic resonance imaging cine-loops, vertical long view, revealing a close relation of the pseudoaneurysm and the left circumflex artery.