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

Iatrogenic non-coronary leaflet perforation as a complication after robotic mitral valve repair

Iatrogenic aortic regurgitation secondary to leaflet injury is a rare complication of mitral valve surgery. For the first time, we report a patient who had progressive aortic regurgitation due to non-coronary leaflet perforation after robotic mitral valve repair and required aortic valve repair 18 months after this initial surgery. As in our case, aortic regurgitation after mitral valve surgery may remain undiagnosed on intraoperative transesophageal echocardiography or undetected until the patient's discharge due to gradual enlargement of very small perforations over the postoperative course.

Iatrogenic Acute Aortic Insufficiency Following Mitral Valve Replacement

Iatrogenic acute aortic insufficiency after heart procedures is rare and it can happen secondary to cusp entrapment, tension, laceration, or perforation. The aortic valve is located anterior and to the right of the mitral valve, which makes it susceptible to damage during mitral valve replacement or repair. We report a 62-year-old male who developed acute aortic valve insufficiency following mitral valve replacement where using an intraoperative transesophageal echocardiogram (TEE) prompted early diagnosis and management. Late diagnosis is usually associated with increased morbidity and mortality. The aortic insufficiency resulted from entrapment of the aortic valve annulus due to suture misplacement at the commissure between the left and noncoronary cusp. This case report shines the light on the importance of a thorough intraoperative TEE during cardiac surgery to early diagnose and treat any complications.

Transesophageal Echocardiographic Assessment of the Repaired Mitral Valve: A Proposed Decision Pathway

The indications for mitral valve repair extend across the entire spectrum of degenerative mitral valve disease, ranging from fibroelastic degeneration to Barlow's disease. Collaboration between the surgeon and anesthesiologist is essential for ensuring optimal results. Echocardiographic assessment of the repair can be challenging but is essential to the success of the procedure, as even mild residual mitral regurgitation can portend poor patient outcomes. In addition to determining the severity of residual regurgitation, the anesthesiologist must elucidate the mechanism of disease in order to inform appropriate re-intervention measures. Finally, there are unique complications of mitral valve surgery for the anesthesiologist to understand and assess by echocardiography. This review describes a systematic pathway for a comprehensive intraoperative assessment of the mitral valve following surgical repair.

Iatrogenic aortic regurgitation following primary closure of ventricular septal defect: Role of transesophageal echocardiography

Iatrogenic valvular regurgitation following cardiac surgery has been reported as a result of leaflet perforation or entrapment. Due to its central location, the aortic valve is one of the most vulnerable structures for iatrogenic injuries. Proper assessment of the aortic valve by transesophageal echocardiography (TEE) should be done after a cardiac surgery in the periaortic area. We hereby report a case of iatrogenic aortic regurgitation which was developed after primary closure of perimembranous ventricular septal defect. It was timely diagnosed by TEE after termination of cardiopulmonary bypass and helped in further management.

Urgent transcatheter aortic valve replacement for severe acute aortic regurgitation following open mitral valve surgery

Transcatheter aortic valve replacement (TAVR) is not currently approved for pure native valve aortic incompetence, and is typically performed on a compassionate basis in selected patients who are at high risk for conventional surgery. We describe the first use of TAVR to treat iatrogenic severe acute pure aortic incompetence following mitral valve surgery. A 71-year-old gentleman developed life-threatening acute aortic regurgitation (AR) within hours of a very challenging fifth open heart mitral valve replacement. Careful inspection of echocardiographic and computed tomographic imaging identified the cause as a disrupted left coronary cusp at the commissure caused by the surgical mitral annular reconstruction. Medical management with afterload reduction failed with recurrent pulmonary edema, and a sixth open heart surgery was deemed prohibitively high risk. The lack of aortic annular calcium onto which anchors a transcatheter valve was a concern for TAVR. However, we postulated that the struts of the mitral valve bioprosthesis would offer some support to the TAVR valve. We opted for a self-expanding system because of concerns about potential unfavorable interaction between the balloon onto which balloon-expandable bioprosthesis is mounted and the struts of the mitral bioprosthesis, and because the Evolut R system has additional anchoring points at the crown which might enhance transcatheter valve stability in the non-calcified annulus, compared with the Edwards Sapien system. Transfemoral TAVR, performed with a Medtronic Evolut R 34 mm system under general anesthesia and using moderately rapid ventricular pacing, was successful with minimal residual AR. On follow-up 1 month later the patient was asymptomatic, and the aortic and mitral bioprostheses were functioning normally on echocardiogram.

A rare complication of mitral valve replacement: Iatrogenic aortic valve perforation

Iatrogenic aortic valve injury after mitral valve surgery is a well-known but rare complication. Herein, we report a 62-year-old male patient who underwent mitral valve replacement surgery 12 years ago and developed moderate to severe aortic regurgitation immediately after surgery.

Iatrogenic Aortic Valve Perforation after Ventricular Septal Defect Repair

Iatrogenic aortic valve (AV) perforation during non-aortic cardiac operations is a rare complication. The suture-related inadvertent injury to an AV leaflet can produce leaflet perforation with aortic regurgitation after ventricular septal defect repair (VSDR). We report three consecutive patients who had iatrogenic aortic leaflet perforation during VSDR in other hospitals and referred to our hospital for reoperation. In all three cases, the perforated AV leaflets were preserved and repaired by autologous pericardial patch or direct local closure.

Distortion of aortic valve from mechanical traction imposed by the mitral valve prosthesis: The three-dimensional transesophageal echocardiographic perception

Iatrogenic injury to the aortic valve is a rare but frequently reported complication during mitral valve surgeries. Intraoperative 2-dimensional transesophageal echocardiography (2D TEE) has a major impact in diagnosing these injuries, so that timely intervention is possible. However, 2D TEE has lot of limitations during the perioperative period, which can be overcome by the three dimensional echocardiography (3D-TEE). We report a case where 3D TEE has undoubtedly delineated the cause for distortion of aortic sinus after mitral valve replacement and helped in the successful outcome.