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Title: 

Trapped Mitral Valve Bioprosthesis: Case Report and Review of the Literature.


Author:

Hisham M.F. Sherif, MD, FACS


Institution:

From the Division of Cardiac Surgery, Christiana Hospital, 
Christiana Care Health System, Newark, Delaware, USA.


Disclosure:

No relevant financial disclosure or conflict of interest


Corresponding Author Information:

Hisham M.F. Sherif, MD, 
FACS, FICS, FACC, FAHA
Division of Cardiac Surgery,
Christiana Hospital, Christiana Care Health System,
4755 Ogletown-Stanton Road, Suite 1E50,
Newark, Delaware 19718, USA
Tel. (302) 733-1980
Fax. (302) 733-1986
Email: HYPERLINK "mailto:hsherif@christianacare.org"hsherif@christianacare.org 


Short Title:

Trapped Mitral Prosthesis










Abstract:


Resection of the anterior leaflet of the mitral valve is a common step in mitral valve replacement procedures. We report a case of a prosthetic valve dysfunction secondary to its entrapment in the preserved native mitral leaflets.  


Keywords:

Mitral Valve. Mitral Valve Replacement. Reoperation. Surgery, complications.


Text Word Count: 1338.

































Text


Introduction:

Resection of the one leaflet (usually the anterior) of the mitral valve is a common step in mitral valve replacement procedures. We report a case of a prosthetic valve dysfunction secondary to being trapped in the preserved native mitral leaflets.  

Case Report:

A 60 year old male with history of controlled hypertension, hyperlipidemia, non-obstructive coronary artery disease, severe pulmonary hypertension, assumed rheumatic mitral valvular disease and chronic diastolic congestive heart failure and persistent atrial fibrillation on warfarin presented to the hospital with persistent and mildly progressive dyspnoea. Trans-esophageal evaluation at admission revealed thickened, minimally calcific mitral leaflets with restricted movement and moderate mitral stenosis with an eccentric jet of severe mitral regurgitation directed anteriorly and encircling the atrial wall, a markedly dilated left atrium with a thrombus in the left atrial appendage. Left ventricular systolic function was preserved, with left ventricular ejection fraction calculated at 60%. 

Subsequently, the patient underwent a mitral valve replacement using a pericardial valve, modified bi-atrial maze procedure using radio-frequency epicardial ablation device and obliteration of the left atrial appendage. Intraoperative inspection of the native valve suggested an old �burn-out� rheumatic mitral valvulitis. A size 25mm valve bioprosthetic pericardial valve was seated in place with sparing of the native mitral valve leaflets and chordal structures. The rest of the procedure as well as the postoperative course were uneventful.

Approximately 2 years afterwards, the patient again began experiencing progressive dyspnoea, shortness of breath and cough, but no fever or chills and a recurrent rapid uncontrolled atrial fibrillation. Upon evaluation prior to cardioversion, a repeat trans-esophageal echocardiography (Figure 1. Video 1) revealed no mitral regurgitation but significant mitral stenosis, with peak velocity across the mitral aperture of 2.3 m/sec. Bioprosthetic leaflets were thickened and the motion of at least one leaflet was significantly restricted. Left ventricular systolic function remained in the 55-60% range.

With these findings, the patient was scheduled for redo-mitral valve replacement. Under conventional cardiopulmonary bypass with bi-caval cannulation, the left atrium was entered using a trans-septal approach. Intra-operative transesophageal echocardiography confirmed the restricted movement of the prosthetic valve. (Figure 2. Video 2) Exposure of the mitral valve revealed the prosthesis to be severely adherent to the walls, the preserved posterior leaflet and postero-medial papillary muscle. Prosthetic valve leaflets were free of calcification but severely restricted by the encroaching deformed leaflet and scar tissue. Dissection of the prosthesis away from the annulus was difficult, requiring a counter-incision in the ascending aorta to facilitate exposure of the anterior annulus and debridement of the subvalvular structures. All remaining native mitral valve tissue, including the chordal structures and the heads of the papillary muscles, were resected. After careful debridement of the annulus, a mechanical prosthesis of appropriate size was seated and the rest of the procedure completed in the conventional manner. Patient was weaned easily from cardiopulmonary bypass without inotropic support. The patient�s postoperative course was uneventful and the patient was discharged home on the fifth postoperative day. 

Pathologic examination of the resected specimens was consistent was myxomatous changes of the valve tissue. Further evaluation of the explanted valve in the operating room (Figure 3) and  by the manufacturer (Figures 4,5) demonstrated extensive fibrotic reaction encompassing the native valve leaflets, encroaching on the prosthetic valve leaflets and causing fusion of leaflet 3 with its adjacent leaflets for a distance of 4-5mm at commissure 3 and 7mm at commissure 1. Laboratory data showed normal to slightly elevated white blood cell count, with normal anti-streptolysin-O titre and elevated C-reactive protein level. All cultures from blood, excised native valve or prosthesis, mitral annulus and intra-cavitary fluids were negative.  In light of the presumptive history of rheumatic disease with questionable active rheumatic valvulitis, the patient was started on oral penicillin per Infectious Diseases specialist.

Comments:
 
Surgery of the mitral valve was among the first procedures envisioned before the emergence of cardiac surgery. In 1897, an article in the Lancet by Dr Milton, a surgeon at the Kasr el-Aini hospital in Cairo, Egypt; describing his sternotomy technique as an access into the chest, also mentioned the possibility of �plastic operations on valvular lesions�. The following year, Dr Samways� article in the same journal anticipated �notching the mitral orifice� to relieve mitral stenosis. Some of the first procedures of closed mitral commissurotomy were by Dr Elliott Culter in Boston in 1923 and Dr Souttar in London in 1925. The first reported case of excision of a part of the valve was by Dr Pribram in Berlin in 1925, using a valvulotome. The introduction of the cardiopulmonary bypass machine in the mid-1950s allowed surgeons to replace diseased valves with mechanical prostheses, with the first mitral valve replacements performed in 1960 by Dr Morrow [1], and Dr Starr in 1961[2], after complete excision of the native valve and transection of the chordae and papillary muscles, to facilitate the insertion of the largest possible prosthesis. This technique was adopted as the surgical standard but was associated with an increased postoperative mortality, deterioration of ventricular function and cases of catastrophic atrioventricular groove disruption. Dr Lillehei, in 1964, introduced the preservation of mitral valve leaflets and chordae, which was associated with lower mortality rates and improved outcomes. In 1972, Dr Kirklin introduced the concept of the loss of systolic unloading from the left ventricle (�pop-off� effect) into the left atrium by mitral valve replacement, thereby increasing left ventricular afterload and wall stress and reducing the ejection fraction. This was proven to be untrue after chordal preservation techniques were implemented. 
 
The mitral valve leaflets are supported by chordae attached to the papillary muscles of the left ventricle. The geometric arrangement of these structures ensures their maximal mechanical efficiency in supporting the coapted leaflets against the considerable forces within the ventricle at the time of systole. The importance of this support was first highlighted by Dr Bailey in the 1940s, who likened it to the effect of ladies� girdles, which he used to sell as a boy. [1] However, The topography of the mitral valve leaflets exhibits considerable and individual variation, with corresponding variation in the mode of chordal support, which may cause a part of the leaflet to be less supported than others [3] 

Three types of chordae are described: Primary and secondary chordae, which arise from the papillary muscle and attach to the leaflet edge and undersurface, respectively; and the tertiary chordae (also termed mural or basal chordae) which arise from the posterior left ventricular wall and insert into the undersurface of the base of the posterior leaflet. [4] Tertiary chordae are thought to have a unique supporting effect of the postero-basal ventricular wall, an area which undergoes a clockwise twisting motion and forward displacement during systole, in contrast to the counter-clockwise and downward movement of the rest of the ventricular mass. [5-10] 

This torsion, i.e. the angular difference in reciprocal twisting of apex and base, was shown to be necessary for the equalization of stresses across the ventricular wall. [11-12] The loss of this support by complete excision of all the chordae is thought to contribute to the uneven distribution of forces that may result in undue stress a the posterobasal segments and thus predisposing for atrioventricular disruption.[13-16]

Beginning in the 1980s, ample experimental and clinical evidence demonstrated the beneficial effects of preserving the chordae tendinae (commonly the anterior) and/or one of the leaflets, most commonly the posterior. Improved mortality rate as well as left ventricular function and ejection fraction have led to this technique being recommended by most of the current authorities in cardiac surgery, and adopted by the majority of surgeons. [17-27] 

Some, as in the case presented, have also preserved the entire native valve leaflets and chordae. The case report confirms earlier reports [28,29] that residual native valve tissue can have a hindering effect on the proper function of the prosthetic valve. Our findings also demonstrate that most of the chordal structures (primary and secondary), and even the heads of the papillary muscles, can be safely excised in patients with preserved left ventricular systolic function without deleterious effects and should be taken into consideration during mitral valve replacement, especially in cases with smaller annular size.

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Figure Legends:



Figure 1: Still frame from the trans-esophageal echocardiogram (Video 1) upon re-admission demonstrating restricted movement of the bioprosthetic valve leaflets.

Figure 2: Still frame from the intra-operative trans-esophageal echocardiogram (Video 2) confirming the restricted movement of the bioprosthetic valve leaflets. 

Figure 3: Intraoperative photograph of the explanted valve demonstrating the remnants of the native mitral valve leaflets severely encroaching on the bioprosthetic valve, immobilizing two of its leaflets.

Figure 4: Photograph from the manufacturing company demonstrating the extensive fibrosis and scarring of the native mitral leaflets. 

Figure 5: Radiologic examination of the explanted bioprosthesis.

Video 1: Trans-esophageal echocardiography performed upon readmission demonstrating the severely restricted movement of the valve prosthesis.

Video 2: Intraoperative trans-esophageal echocardiography demonstrating only one moving leaflet of the bioprosthetic valve.










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