Severe regurgitation due to perforation of the mitral-aortic intervalvular fibrosa 3 years after aortic valve replacement

New or Worsened Mitral Regurgitation After Surgical Aortic Valve Replacement: A Systematic Review

BACKGROUND

New or worsened mitral regurgitation (MR) is an uncommon yet serious complication after surgical aortic valve replacement (SAVR). While there have been numerous reports of its occurrence, there is little consensus regarding its presentation and management. This systematic review summarizes the evidence in the current literature surrounding new or worsened MR after SAVR and analyzes its potential implications.

METHODS

Databases were examined for all articles and abstracts reporting on new or worsened MR after SAVR. Data collected included number of patients studied; patient characteristics; incidences of new or worsened MR; timing of diagnosis; and treatment.

RESULTS

Thirty-six full-text citations were included in this review. The prevalence of new or worsened MR after SAVR was 8.4%. Sixteen percent of new MR occurrences were from an organic etiology, and 83% of new MR occurrences were that of a functional etiology. Most diagnoses were made in the late or unspecified postoperative period using echocardiography (range: 0 minutes to 18 years postoperatively). While no patients died from this complication, 7.7% of patients (16 out of 207) required emergent procedural re-intervention.

CONCLUSIONS

This systematic review underscores the importance of identifying new or worsened MR following SAVR and accurate scoring of MR severity to guide treatment. It also outlines the associated clinical measures commonly documented following this complication, and the usefulness of transesophageal echocardiography for the detection of significant MR. These results reflect the current, limited state of the literature on this topic and warrant further investigation into MR detection and management strategies in SAVR patients.

Iatrogenic aortic insufficiency following mitral valve replacement: case report and review of the literature

We report a 28-year-old white female who suffered significant aortic insufficiency (AI) following mitral valve (MV) replacement for endocarditis. The patient had history of rheumatoid arthritis and presented to our emergency department with a 3-month history of dyspnea, orthopnea, fevers and weight loss, worsening over 2 weeks, for which she took intermittent acetaminophen. On admission, vital signs revealed blood pressure of 99/70 mm Hg, heart rate of 120 beats/minute, and temperature of 98.8 °F; her weight was 100 lbs. Physical exam revealed a thin and pale female. Cardiac auscultation revealed regular tachycardic rhythm with a third heart sound, and a short early systolic murmur at the left lower sternal border without radiation. Lungs revealed right lower lobe rhonchi. Initial pertinent laboratory evaluation revealed hemoglobin 9.6 g/dL and white blood cell count 17,500/μL. Renal function was normal, and hepatic enzymes were mildly elevated. Chest radiogram revealed right lower lobe infiltrate. Blood cultures revealed Enterococcus faecalis. Two-dimensional echocardiogram revealed large multilobed vegetation attached to the anterior MV leaflet with severe mitral regurgitation (MR), otherwise normal left ventricular systolic function. She was started on appropriate antibiotics and underwent MV replacement with 25-mm On-X prosthesis. She was noted post-operatively to have prominent systolic and diastolic murmurs. Repeat echocardiogram revealed normal mitral prosthesis function, with new moderately severe AI. Transesophageal echocardiogram revealed AI originating from a tethered non-coronary cusp, due to a suture preventing proper cusp mobility. The patient declined further surgery. She recovered slowly and was discharged to inpatient rehabilitation 4 weeks later. This case highlights the importance of vigilance to this potential serious complication of valve surgery with regard to diagnosis and treatment to prevent long-term adverse consequences.

Pseudoaneurysm of the mitral-aortic intervalvular fibrosa. A new comprehensive review

Pseudoaneurysm of the mitral-aortic intervalvular fibrosa (P-MAIVF) is an infrequent but potentially life-threatening condition. Both transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) can detect P-MAIVF with sensitivity rates of 43 and 90 %, respectively. The typical finding of echocardiography is a pulsatile echo-free sac that expands in systole and collapses in diastole. Our review comprises 166 patients with P-MAIVF, including eight cases in our hospital and 158 cases from the literature. P-MAIVF is often associated with infection or surgical trauma. While it is likely to maintain an asymptomatic course, symptoms of shortness of breath, heart failure, valvular disease, chest pain, endocarditis, and cerebrovascular events are common clinical presentations. The recommended treatment is surgery. However, conservative therapy is an alternative approach for high-risk patients or when surgical treatment is refused. With the increasing incidence of cardiac surgery and infective endocarditis, a likely increment in the new diagnosis of pseudoaneurysm is expected.

Perforation of mitral-aortic intervalvular fibrosa secondary to bicuspid aortic valve endocarditis: Possible relation with diagnostic coronary angiography

Infective endocarditis (IE) remains a serious and deadly disease despite recent advances in diagnosis and treatment. In all IE cases, the rate of healthcare-associated IE has been reported as 23%. Aortic valve endocarditis may extend to mitral-aortic intervalvular fibrosa (MAIVF), which may cause pseudoaneurysm formation and subsequent perforation. Direct perforation of the MAIVF is a rare clinical finding. In this report, we present a case of bicuspid aortic valve endocarditis which manifested as acute heart failure secondary to perforation of MAIVF and developed after diagnostic coronary angiography. <Learning objective: Direct perforation of MAIVF without abscess or aneurysm formation is a rare complication of IE. Health-care associated IE (HAIE) occurs mostly secondary to vascular manipulations and coronary angiography (CAG) is a rare cause of HAIE. Here, we report a case of aortic valve IE which developed two weeks after CAG and was complicated with perforation of MAIVF. Staphylococcus epidermidis was the causative microorganism. Urgent surgical treatment resulted in complete recovery of the patient.>.