Left ventricular–right atrial communication following tricuspid annuloplasty

Abstract

A 71-year-old woman was admitted for examination of a heart murmur and anemia. She had a history of mitral valve replacement and tricuspid ring annuloplasty 8 months prior to admission. A new systolic murmur was heard, and echocardiography showed a high-velocity jet originating from the left ventricular outflow tract to the right atrium and a small defect between the left ventricle and the right atrium. No periprosthetic leaks were detected in the mitral position. At operation, a communication just beneath the detached prosthetic ring at the anterior-septal commissure of the tricuspid valve, and a jet of bright red blood entering the right atrium through the defect at the atrial septum just cephalad to the commissure, were found. After removing the ring, the defect was closed using a mattress suture. In this case, the tricuspid annuloplasty ring was probably placed on the atrio-ventricular portion of the membranous septum, rather than the tricuspid annulus, at the antero-septal commissure of the tricuspid valve in the previous operation, and its dehiscence may have created a tear in the atrio-ventricular membranous septum, leading to left ventricular-right atrial communication.

Iatrogenic left ventricular-right atrial communication after tricuspid annuloplasty; a case report

“…Trauma to the membranous septum could therefore result in either a ventricular septal defect or an LV-RA communication. According to Aoyagi et al, if a mattress suture for TAP is inserted into the atrioventricular portion of the membranous septum rather than the tricuspid annulus at the anteroseptal commissure of the tricuspid valve, dehiscence of the ring and creation of a tear of the atrioventricular membranous septum may occur [7]. We speculated that a similar phenomenon had occurred in our case.…”

“…We speculated that a similar phenomenon had occurred in our case. Interestingly, all previously reported LV-RA communication after TAP, including the present case, used a rigid ring [7,8], suggesting that strong tension around the tricuspid annulus associated with a rigid ring may lead to increased risk for LV-RA communication.…”

“…Iatrogenic LV-RA communication caused by TAP suturing has been also reported, but it is extremely rare [7,8]. Anatomically, the line of attachment of the septal leaflet of the tricuspid valve crosses the membranous septum, dividing it into an anterior interventricular portion, which lies between the ventricles, and a posterior atrioventricular portion, which lies between the left ventricle and right atrium.…”

“…Acquired left ventricular-right atrial (LV-RA) communication following aortic or mitral valve replacement is reported to occur infrequently [1-6], but LV-RA communication can also result from tricuspid annuloplasty (TAP) [7,8]. We present a case of iatrogenic LV-RA communication associated with TAP with a rigid prosthetic ring.…”

The Gerbode Defect: Left Ventricular to Right Atrial Communication—Anatomic, Hemodynamic, and Echocardiographic Features

“…LV–RA shunts are a rare complication of surgery performed near the membranous septum. Cases have been reported following mitral valve replacement, 9,10 aortic valve replacement, 11–14 and combined tricuspid annuloplasty ring insertion/mitral valve replacement 15,16 . In this respect, injury to the membranous septum caused by excessive debridement of annular calcium may be of particular importance 9–11 .…”