Severe bioprosthetic mitral valve stenosis in pregnancy

A 21-year-old woman in the 16th week of pregnancy was admitted due to acute presentation of severe exertional dyspnea. She had undergone mitral valve replacement (MVR) with bioprosthetic valve for infective endocarditis 2 years ago. She developed congestive heart failure from mitral bioprosthetic valve stenosis due to early structural valve deterioration. She also had severe pulmonary hypertension and underwent a redo MVR using a mechanical valve prosthesis with good maternal outcome but fetal demise. This report brings up the debate about what type of valve should be used in women in reproductive age, and discusses the management of severe mitral stenosis and stenosis of a bioprosthetic valve during pregnancy. Surgical options can almost always be delayed until fetal maturity is achieved and a simultaneous cesarean section can be performed. However, under certain circumstances when the maternal welfare is in jeopardy the surgical intervention is mandatory even before the fetus reaches viability.     

Implantation of a mechanical valve in a previously implanted mitral bioprosthetic orifice in a patient with mitral bioprosthetic failure

Complete removal of a previously implanted dysfunctional mitral bioprosthesis could result in extensive damage. Therefore, a 66-year-old female patient with a deteriorated mitral bioprosthesis had leaflet excision, and a “new” mechanical valve was sewn onto the previously implanted bioprosthetic sewing cuff. On postoperative echocardiography, the implanted valve had good hemodynamic performance with no paravalvular leakage. The patient's clinical condition improved after surgery.     

Cesarean section in a patient with severe mitral stenosis after mitral valve replacement

A 30-year-old woman with mitral stenosis after mitral valve replacement was scheduled for cesarean section at 28 weeks and 6 days of pregnancy. Cesarian section was decided at a conference of obstetrics, cardiac surgery, neonatology and anesthesiology. Anesthesia was successfully managed with epidural block and pulmonary arterial pressure monitoring. During operation, blood pressure was controlled by dopamine, milrinone and phenylephrine. Patient did not develop cardiac insufficiency perioperatively. Cardiac function deteriorated gradually and reoperation of mitral valve replacement was performed 2 months later.     

Anesthetic management for mitral valve replacement in a patient with mitral stenosis and dilated cardiomyopathy

A 69-year-old man who has mitral stenosis concomitantly with dilated cardiomyopathy underwent mitral valve replacement. The preoperative left ventricular ejection fraction was 23%. Preoperative dobutamine stress echocardiography showed poor response. High dose fentanyl was administered for induction and maintenance of general anesthesia, and blood pressure was kept with vasoconstrictors. Circulatory assist with milrinone and intraaortic balloon pumping after the cardiopulmonary bypass enabled us to obtain stable hemodynamics.     

Mitral bioprosthetic valve stenosis in a patient with antiphospholipid antibody syndrome and systemic lupus erythematosus

A 45-year-old woman with antiphospholipid antibody syndrome (APS) and systemic lupus erythematosus was admitted because of severe dyspnea. She had undergone mitral valve replacement (MVR) using a Mosaic bioprosthesis for infective endocarditis 9?years previously. She developed congestive heart failure secondary to mitral bioprosthetic valve stenosis resulting from relatively early structural valve deterioration. She underwent a second MVR using a mechanical valve prosthesis. The explanted bioprosthesis showed marked pannus formation and mineralization with fibrin thrombus formation, especially on the outflow surfaces of the leaflets. After the second operation, she was discharged without APS-related thromboembolic events under meticulous anticoagulant and antiplatelet therapies.     

Anesthetic management for mitral valve replacement in a patient with mitral stenosis and dilated cardiomyopathy]

A 42-year-old man with dilated cardiomyopathy and rheumatic mitral stenosis underwent mitral valve replacement. Prior intravascular fluid administration and infusion of dopamine and dobutamine stabilized hemodynamics during the induction of anesthesia. High-dose fentanyl at pre-cardiopulmonary bypass period and circulatory assist with milrinone and intraaortic balloon pumping after the bypass enabled us to obtain stable hemodynamics. Preoperative dobutamine stress test provided us the effective information for circulatory management in this patient.     

Severe stenosis of bioprosthetic valve due to late valve thrombosis

The typical cause of bioprosthetic valve dysfunction over years is calcification of leaflets, pannus formation, or tears due to structural degeneration. Thrombosis is rare as the valves get endothelialized early on, and, hence, anticoagulation is not recommended beyond 6 months after valve replacement. While bioprosthetic valve thrombosis is unusual (0.03% to 0.34%/year), it can be associated with significant mortality and morbidity. Here, we present a case of a middle-aged man with history of bioprosthetic mitral valve who presented with syncopal episode and was referred to us for mitral valve replacement for tentative bioprosthetic valve degeneration and stenosis. However, preoperative work up revealed prosthetic valve thrombosis which was successfully treated with anticoagulation.     

Aortic valve papillary fibroelastoma in a patient with mitral valve regurgitation

Papillary fibroelastoma is a rare cardiac tumour. We describe a patient with mitral valve regurgitation and aortic valve papillary fibroelastoma. The patient was 62-year-old woman. She was referred to us for surgical treatment of mitral valve. Preoperative echocardiography showed rheumatic mitral valve regurgitation (Sellers grade III) and it also demonstrated mobile masses of the aortic valve. At operation, mitral valve was repaired by a posterior annuloplasty. Through the aortotomy, small tumors were found to be attached to each cusps of the aortic valve and they were successfully removed. The histopathologic diagnosis was papillary fibroelastoma of the aortic valve. The postoperative course was uneventful.     

Ruptured mitral valve aneurysm in a patient with quadricuspid aortic valve

Mitral aneurysm is commonly associated with infectious endocarditis of the aortic valve. In rare instances, it is associated with other underlying inflammatory or metabolic disorders. A 62-year-old man with mitral valve insufficiency with moderate aortic valve insufficiency underwent operation. Operative findings were the ruptured aneurysm of the mitral valve in association with the calcified quadricuspid aortic valve. There was no evidence of infection in the mitral valve and the aortic valve. The mitral valve was repaired, the aortic valve replaced, and Cox Maze procedure added. A rare combination of mitral and aortic valve lesions without endocarditis suggested that mechanical stress alone may induce mitral valve aneurysm.     

An unusual case of bioprosthetic mitral valve thrombosis

Bioprosthetic valve thrombosis and related embolism are considered extremely unlikely, thus allowing most patients to avoid long-term anticoagulation. There is, however, limited experience in the diagnosis and treatment of such a condition. We present the case of a patient with a porcine mitral bioprosthesis who presented with acute thrombosis with unusual echocardiographic features. A favorable outcome was observed after conventional anticoagulant treatment.     

Papillary fibroelastoma of the mitral valve associated with rheumatic mitral valve stenosis

With the advent of echocardiography, diagnosis of papillary fibroelastoma in living patients has been made possible, yet papillary fibroelastoma found in the living remains a very rare cardiac tumor. We report a case of papillary fibroelastoma of the mitral valve with rheumatic mitral valve stenosis. A 68-year-old woman was referred to our hospital with a mitral valve tumor and rheumatic mitral valve stenosis. She underwent anticoagulation therapy with Warfarin for 8 years since having a cerebral embolization. Echocardiography revealed a mass attached to the mitral valve, with severe mitral valve stenosis. Electrocardiography demonstrated a chronic atrial fibrillation. Tumor excision with mitral valve replacement and maze procedure were performed. Both the surgical and histological findings depicted papillary fibroelastoma. The postoperative course was uneventful and the patient has remained symptom-free one year after surgery.     

Early acute thrombosis of bioprosthetic mitral valve presenting with cardiogenic shock

Early thrombosis of bioprosthetic mitral valves is an extremely rare occurrence. We present an unusual case of a patient with polycythemia presenting with cardiogenic shock, secondary to acute thrombosis of a bioprosthetic mitral valve which was placed 14 months prior to presentation. Our report also reviews predisposing factors and treatment options for bioprosthetic mitral valve thrombosis.     

A case of mitral valve replacement with autologous pulmonic valve in congenital mitral stenosis

A one-year-old infant with congenital mitral stenosis and pulmonary hypertension underwent by mitral valve replacement with his pulmonic valve autograft and pulmonary tract reconstruction with heterogeneous pericardial conduit. His postoperative hemodynamics data showed that left atrial pressure decreased and pulmonary hypertension continued. Echocardiography showed that the implanted autograft functioned properly. On the seventh postoperative day, he died of pulmonary hypertension. In case with congenital mitral stenosis with the small mitral annulus and the small left ventricular cavity, it is difficult to perform mitral valve replacement by commercially available mechanical or tissue valves. Because these valves are not suitable for the small mitral annulus. The mitral valve replacement with pulmonic valve autograft is recommended in such a case with the congenital mitral stenosis.     

Direct transatrial transcatheter SAPIEN valve implantation through right minithoracotomy in a degenerated mitral bioprosthetic valve

Transcatheter valve implantation into failing surgical mitral bioprosthetic valves have been reported. This strategy avoids performing high-risk repeat cardiac surgery in elderly patients with multiple comorbidities. All these patients have been treated by a transapical approach. We report a case of failing bioprosthetic mitral valve in an 82-year-old woman successfully treated with a 29-mm Edwards SAPIEN balloon expandable bioprosthesis (Edwards Lifesciences, Irvine, CA) with direct left atrial approach through a right anterior thoracotomy. Our experience demonstrates the technical feasibility and safety of this approach. Therefore, mitral valve-in-surgical valve implantation may be a viable treatment alternative in carefully selected patients.