CASE REPORT |
https://doi.org/10.5005/jp-journals-10034-1130 |
Prosthetic Mitral Valve Prolapsing into the Left Atrium: Identifying the Pathology with Transesophageal Echocardiography: A Case Report
1–4Department of Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
5,6Department of Cardiovascular and Thoracic Surgery, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
Corresponding Author: Rajarajan Ganesan, Department of Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India, Phone: +91 9815930510, e-mail: Raja2n@gmail.com
Received: 12 May 2023; Accepted: 04 June 2023; Published on: 20 February 2024
ABSTRACT
Background: Left atrial dissection presents as a rare complication post-mitral valve surgery. Its presentation can be varied, from asymptomatic to severe hemodynamic instability, which needs a prompt diagnosis.
Case presentation: Here we present a case of left atrial dissection late after aortic and mitral valve replacement, identified on preoperative transesophageal echocardiography which facilitated proper diagnosis and management..
How to cite this article: Jhawar VS, Ganesan R, Reddy P, et al. Prosthetic Mitral Valve Prolapsing into the Left Atrium: Identifying the Pathology with Transesophageal Echocardiography: A Case Report. J Perioper Echocardiogr 2021;9(2):33–36.
Source of support: Nil
Conflict of interest: None
Patient consent statement: The author(s) have obtained written informed consent from the patient for publication of the case report details and related images.
Keywords: Case report, Left atrial dissection, Mitral valve surgery, Transesophageal echocardiography
INTRODUCTION
Left atrial dissection is a rare but potentially severe complication that can occur after mitral valve replacement surgery, with an incidence of 0.16%.1 It can present as a new onset systolic murmur associated with symptoms of heart failure, pulmonary hypertension, or low cardiac output syndrome.2
CASE DESCRIPTION
A 47-year-old male underwent replacement of aortic and mitral valves 10 years prior for rheumatic heart disease with severe mitral stenosis, moderate mitral regurgitation, and moderate aortic regurgitation. Following the surgery, he was asymptomatic till one year back when he developed generalized weakness and palpitations. On echocardiography, his prosthetic mitral valve was identified to be prolapsed into the left atrium (LA) with severe left ventricle systolic dysfunction, and he was planned for redo mitral valve replacement (Figs 1 and 2 and Videos 1 and 2).
Fig. 1: Apical four-chamber viewing showing the prosthetic mitral valve prolapsed into the left atrium; LV, left ventricle; RA, right atrium; RV, right ventricle
Fig. 2: Parasternal long-axis view showing the displaced prosthetic mitral valve; LA, left atrium; LV, left ventricle; RV, right ventricle
On examination, his heart rate was 125/minute, irregularly irregular, and his blood pressure was 116/55 (80) mm Hg. On auscultation, a systolic murmur was heard in the left lateral position. On the day of surgery, after induction of general anesthesia, transesophageal echocardiography was performed. In the mid-esophageal four-chamber view, the mitral valve was seen detached from its native annular position (Fig. 3 and Video 3). In addition, in the mid esophageal two-chamber, tissue accompanied the detached prosthesis, forming an echolucent chamber within the LA (Fig. 4 and Video 4). In the midesophageal long-axis view, the prosthesis was seen detached from the posterior annulus, and the false chamber formed by the prosthesis was found to share a common wall with the LA, thus confirming a left atrial dissection (Fig. 5 and Video 5).
Fig. 3: Midesophageal four-chamber view showing the displaced prosthetic mitral valve; LA, left atrium; LV, left ventricle; RV, right ventricle
Fig. 4: Midesophageal two-chamber view showing the displaced prosthetic mitral valve with tissue accompanying the displaced prosthesis; LA, left atrium; LV, left ventricle
Fig. 5: Midesophageal aortic valve long-axis view showing the left atrial dissection; LA, left atrium
Further increasing the omniplane angle to 150°, the dissection got delineated better (Fig. 6 and Video 6). The three-dimensional narrow-angle echo loop and the three-dimensional focussed view from the LA are shown in Videos 7 and 8. After the institution of cardiopulmonary bypass and aortic cross-clamping, the mitral valve was approached via the right atrium (Fig. 7). The prolapsed valve was explanted, and the dissected wall was visualized (Fig. 8). Mitral valve replacement was done with a 23 mm St. Jude Medical valve with pledgets sutures taking bites from both the annulus and the LA. Post-cardiopulmonary bypass transesophageal echocardiography showed the placement of the normally functioning new prosthesis at the native annular position (Figs 9 and 10 and Videos 9 and 10). Postoperatively, he was hemodynamically stable and was discharged from the hospital after 10 days.
Fig. 6: Midesophageal aortic valve long-axis view showing better delineation of the dissection; LA, left atrium
Fig. 7: Surgical view of the displaced prosthetic mitral valve approached through the interatrial septum; RA, right atrium
Fig. 8: Surgical view after explanation of the displaced prosthetic valve showing the edge of the dissection
Fig. 9: Post-cardiopulmonary bypass midesophageal long-axis view showing the normally functioning new mitral valve prosthesis; LA, left atrium
Fig. 10: Three-dimensional zoom view of the normally functioning new mitral valve prosthesis
DISCUSSION
The most common cause of a new onset systolic murmur post-mitral valve replacement is valve dehiscence, the incidence being 7–17%. When it presents with hemodynamic instability, it warrants urgent explantation and replacement of mitral valve prosthesis. Valve dehiscence or prolapse causing acute onset severe mitral regurgitation leads to decompensated right heart failure with severe pulmonary arterial hypertension due to the inability of the LA to incorporate the sudden volume overload. This, accompanied by left atrial dissection, is a very rare but potentially severe complication.1 Left atrial dissection is a condition in which a tear or separation occurs within the layers of the left atrial wall.
Left atrial dissection can present days to years after mitral valve repair and, in a few cases, has been noted to involve the atrial septum. The presentation can vary from benign findings on transesophageal echocardiography to heart failure, pulmonary hypertension, or low cardiac output syndrome. It can present either in a stable or unstable form.3 Most common presenting symptoms are chest pain, palpitations, fatigue, and syncope. It can also present as a sudden hemodynamic change postcardiopulmonary bypass weaning.3 When it causes rupture of the wall of the atria, it can also present with shock and hypotension similar to features of a tamponade, needing urgent intervention. The posterior annulus of the mitral valve is weak due to a lack of fibrous support. Hence valve rupture or prolapse is expected at this level. Left atrial dissection post-mitral valve surgeries are most likely due to atrioventricular separation or rupture of the posterior annulus of the mitral leaflet. Further aggressive debridement of the posterior annulus during surgery or mechanical stress due to an oversized prosthesis or any preexisting atrial wall abnormality can lead to dissection.1 Left atrial dissection can also be identified incidentally and, when associated with minimal hemodynamic instability, can be managed conservatively.2 On the other hand, there may be a need to marsupialize the cavity to prevent any increase in dissection further.1
The diagnosis of left atrial dissection can be facilitated by transesophageal echocardiography since the probe’s location is closest to the LA.4 Prosthetic valve prolapse warrants an immediate replacement of the prosthesis. However, diagnosing a concurrent atrial dissection may necessitate transesophageal echocardiography to identify the separation in the left atrial wall and assess the size, location, and progression of the dissection. Albeit a rare diagnosis, one should always anticipate sudden decompensation in cases presenting with left atrial dissection post mitral valve replacement surgery.
CONCLUSION
The identification of left atrial dissection in a patient with prosthetic aortic and mitral valves was facilitated by using perioperative transesophageal echocardiography allowing for ease in surgical management.
SUPPLEMENTARY MATERIAL
The supplementary videos 1 to 10 are available online on the website of www.jpecardio.com
Video 1: Apical four-chamber viewing showing the prosthetic mitral valve prolapsed into the left atrium
Video 2: Parasternal long-axis view showing the displaced prosthetic mitral valve
Video 3: Midesophageal four-chamber view showing the displaced prosthetic mitral valve
Video 4: Midesophageal two-chamber view showing the displaced prosthetic mitral valve with tissue accompanying the displaced prosthesis
Video 5: Midesophageal aortic valve long-axis view showing the left atrial dissection
Video 6: Midesophageal aortic valve long-axis view showing better delineation of the dissection
Video 7: Three-dimensional narrow-angle view of the displaced mitral valve
Video 8: Three-dimensional zoom view of the mitral valve from the left atrium
Video 9: Post-cardiopulmonary bypass midesophageal long-axis view showing the normally functioning new mitral valve prosthesis
Video 10: Three-dimensional zoom view of the normally functioning new mitral valve prosthesis
ORCID
Rajarajan Ganesan https://orcid.org/0000-0002-9984-7150
REFERENCES
1. Arora D, Mishra M, Mehta Y, et al. A case of left atrial dissection after mitral valve replacement. Ann Card Anaesth 2018;21(3):297–299. DOI:10.4103/aca.ACA_118_17
2. Kim KW, Kim JH, Park SH, et al. Left atrial wall dissection after mitral valve replacement. J Cardiovasc Ultrasound 2013;21(3):145–147. DOI:10.4250/jcu.2013.21.3.145
3. Fukuhara S, Dimitrova KR, Geller CM, et al. Left atrial dissection: etiology and treatment. Ann Thorac Surg 2013;95(5):1557–1562. DOI:10.1016/j.athoracsur.2012.12.041
4. Tang D, Liu H. Acute left atrial intramural wall dissection after mitral valve replacement. J Cardiothorac Vasc Anesth 2011;25(3):498–500. DOI: 10.1053/j.jvca.2011.02.010
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