Severe mitral regurgitation due to geometric changes in the mitral valve after surgical aortic valve replacement

Abstract

Background: Severe mitral regurgitation (MR) after aortic valve replacement (AVR) is a serious complication. Although several causes of MR after AVR have been reported, severe MR due to geometric changes in the mitral valve imposed by an aortic valve prosthesis has not been reported. We here report a case of severe MR after AVR that was improved after re-AVR. Case presentation: A 77-year-old male underwent elective total aortic arch replacement and AVR. Mild MR was preoperatively identified. After surgery and separation from cardiopulmonary bypass, transesophageal echocardiography (TEE) demonstrated restriction and distortion of the anterior mitral leaflet and severe MR. Displacement of the anterior mitral annulus by the prosthetic aortic valve was strongly suspected to be the cause of MR, which should be surgically restored. Re-AVR using a small-sized valve was then performed. Consequently, the structural changes in the mitral valve were reverted and the MR was reduced. Conclusions: Geometric changes in the mitral valve induced by an aortic valve prosthesis can cause massive increment of MR. Intraoperative TEE examination of the mitral apparatus is important when severe MR occurs after AVR.

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

“…Across all studies, a total of patients underwent SAVR. The type of prosthesis used differed between the included studies, with 13 3,20,21,[23][24][25][26]30,33,39,41,44,47 implanting a bioprosthesis, 8 15,16,19,29,34,35,40,42 implanting a mechanical prosthesis, and 3 1,36,37 implanting mechanical and biological protheses; 12 studies 22,27,28,31,32,38,43,45,46,[48][49][50] did not specify prosthesis type. The size of the implanted prosthesis ranged from 17 mm 45 to 27 mm 20,24 ; however, 14 studies 1,[27][28][29]31,32,36,37,43,[46][47]…”

“…The etiology of MR was reported for 120 3,15,16,[19][20][21][22][23][24][25][26][28][29][30][31]33,34,[39][40][41][42][43][44][45][46][47][48][49][50] of the 207 cases of new or worsened MR following SAVR (Table 3). Notably, the mechanism of new or worsened MR was unspecified in the remaining 87 patients.…”

“…1,27,32,36,37,42,43 Organic Etiology. A total of 15.97% (20/120) of reported MR were classified as organic (ie, Carpentier's Type I or Type II), with 70.00% (14/20) 15,16,19,22,23,28,31,34,41,44,46,49 being classified as Type I, and 30.00% (6/20) 21,40,45,46 being classified as Type II. Of the 20 cases of organic MR (ie, Carpentier's Type I and Type II), 30.00% (6/20) 15,23,28,38,41,44,46 were thought to be caused by an extravalvular mechanism, and 70.00% (14/20) 16,19,21,22,31,37,40,45,46,49 by an intravalvular mechanism.…”

“…For the extravalvular causes of MR (n = 6), 15,23,28,38,41,44,46 a foreign body was found to interfere with and damaged the otherwise healthy mitral valve. In 5 patients, 28,38,41,44,46 the implanted prosthetic aortic valve interfered with mitral valve function and damaged the anterior mitral valve leaflet (AMVL).…”

“…For the extravalvular causes of MR (n = 6), 15,23,28,38,41,44,46 a foreign body was found to interfere with and damaged the otherwise healthy mitral valve. In 5 patients, 28,38,41,44,46 the implanted prosthetic aortic valve interfered with mitral valve function and damaged the anterior mitral valve leaflet (AMVL). In the remaining 2 cases, 15,23 the suture line securing the aortic prosthesis damaged the aortomitral curtain 23 or the anterior aspect of the mitral valve.…”