Embolization of disc occluder of a Wada-Cutter mitral prosthesis with survival.

The second recorded survivor following emergency prosthesis replacement after embolization of the Teflon disc occluder of a Wada-Cutter mitral valve is reported. Difficulties encountered while attempting to locate the missing occluder are presented and a useful operative technique for aortic control is described. A plea is made for incorporation of a radiopaque material during manufacture of all future valve poppets.     

Repair of paravalvular prosthetic mitral valve leaks with septal occluder devices in severely high-risk patients: a word of caution

Paravalvular leak following a mitral valve replacement is a complication seen in approximately 1 of 10 replacements. The corrective method has traditionally been reoperation. Septal occluder devices are more commonly being utilized as an alternative percutaneous correction method. We report the use of septal occluder devices in the repair of mitral paravalvular leak in two patients at severely high EuroSCORE II mortality risk. In both patients, the occluder devices became unstable, leading to a recurrence of severe paravalvular leak.     

Mechanical prosthetic valve dysfunction causing pulsus alternans leading to intermittent electromechanical dissociation: a case report and literature review

We describe a case of electromechanical dissociation (EMD) in a 62-year-old female patient following insertion of a Medtronic Hall mitral valve prosthesis. She initially developed pulsus alternans which led, over a few hours, to intermittent electromechanical dissociation. Clinical and echocardiographic findings are described. Emergency surgical intervention revealed a piece of chorda wedged between the disc occluder and the valve ring. This case illustrates clinical and Doppler echocardiographic features associated with a rare presentation of an unusual perioperative complication of prosthetic mitral valve dysfunction. We have also included a brief review of related literature.     

Retrograde (atrial) dislodgement of a Cross-Jones mitral valve occluder

Fatal atrial dislodgement of a lenticular disc occurred seven years after surgery in a 54-year-old patient, who had had a mitral valve replacement with a Cross-Jones prosthesis, for ruptured chordae tendinae. A marked distortion of the titanium ring reinforced silicone rubber lens disc due to material wear was the cause of this complication. From the literature available to us, atrial dislodgement of a prosthetic mitral occluder has not been previously recorded. We therefore intend to recommend elective replacement of the Cross-Jones prosthesis in all patients who have had their artificial valve functioning for more than five years.     

Isolated mitral valve replacement with the Bj?rk-Shiley tilting disc valve prosthesis. A six-year review and a comparison between the Delrin and the pyrolytic carbon disc models.

Replacement of the mitral valve with the Bj?rk-Shiley tilting disc valve prosthesis was performed in 203 consecutive patients with isolated mitral valvular disease at Karolinska Sjukhuset, Stockholm, Sweden, during the 6-year period ending December 1975. Results with the Delrin and pyrolytic carbon disc prostheses were analysed with actuarial techniques and compared in terms of mortality rate, incidence of thrombo-embolism and frequency of re-operation. Early (4%) and late mortality rates (7.5 deaths per 100 patient years) were similar with both types of prostheses. No case of primary mechanical prosthetic failure was encountered. The pyrolytic carbon disc prostheses have obviously decreased the incidence of systemic emboli from 9.6 to 5.3 per 100 patient years and so far eliminated mortality due to embolization. This benefit is probably related to the increased opening angle from 50 degrees to 60 degrees in the pyrolytic carbon disc model, which causes less resistance to blood flow. Thrombotic obstruction of the prosthetic valve, however, has been a persistent problem in the order of 3.3 incidences per 100 patient years. Only one patient in twelve involved was referred to our clinic and could be saved by an emergency re-operation. The development of the ring-shaped radiopaque marker in the tilting disc occluder provides a valuable tool for instant diagnosis of partly or completely obstructed disc motion caused by thrombosis. Disc motion can be easily visualized by cineradiography or fluoroscopy. Early diagnosis of and emergency operation for thrombotic obstruction of the prosthesis will reduce the mortality due to this dangerous complication.     

In Vivo Evaluation of the Lillehei-Kaster Heart Valve Prosthesis

In vivo evaluation of the Lillehei-Kaster heart valve prosthesis was performed in 28 patients; 22 had undergone aortic valve replacement and 6 had had mitral valve replacement.Mean pressure gradients ranged from 6 to 53 mm Hg in aortic prostheses; valve area varied from 0.83 to 2.9 cm². The maximum opening angle of 80 degrees was never reached in this group of patients; opening angles ranged from 57 to 74 degrees without evidence of disc malfunction. There was no correlation between the ratio of effective to geometric valve area and the degree of opening of the disc occluder.Similar results were found in the mitral valve group. Gradients ranged from 6.0 to 12.5 mm Hg and valve area from 1.6 to 2.2 cm². The maximum opening angle was 59 to 63 degrees.It is concluded that incomplete opening of the disc occluder in pivoting-disc valves is not necessarily a sign of disc malfunction. Lillehei-Kaster valves smaller than 18 mm in internal diameter should be avoided in adults, and outflow aortoplasty for implantation of a larger prosthesis should be used in patients who have a narrow aortic root.     

Survival following fracture of strut from mitral prosthesis with disc translocation.

Mechanical complications of prosthetic valves are increasingly rare. The acute, catastrophic nature of the symptoms associated with massive transvalvular regurgitation preclude survival except with immediate operation. In the patient described herein, two weld fractures of a Bj?rk-Shiley mitral prosthetic strut led to displacement of the valve occluder into the left atrium. The patient survived reoperation, following which the strut was detected radiologically in the left ventricular free wall. A slow, limited recovery resulted from his 5 preoperative hours of deep shock and coma. No complication attributable to the retained ventricular foreign body has been identified.     

Early Calcification and Obstruction of a Mitral Porcine Bioprosthesis

A patient is described in whom severe prosthetic valvular stenosis developed ten months after mitral valve replacement with an Angell-Shiley porcine heterograft. At emergency operation, calcification of the prosthesis was revealed. Early calcification and stenosis of a porcine heterograft valve is a life-threatening complication that must be recognized promptly and treated by emergency valve replacement.     

A 22-year course of the Kay-Shiley disc valve with muscle guard at the mitral position

Almost 33 years have elapsed since the introduction of the Kay-Shiley disc valve in Japan. Following the developement of pyrolite carbon, the Kay-Shiley valve is no longer in clinical use. We report the case of a female patient who had had an isolated mitral valve replacement with the Kay-Shiley disc valve with single muscle guard 22 years previously. After numerous thromboembolic episodes with the Kay-Shiley disc valve, a successful reoperation was done with the CarboMedics valve. The explanted valve revealed that the grooved occluder disc had a loosely adherent clot The thromboembolism is a notorious complication associated with this valve. We recommend re-replacement of the Kay-Shiley valve whenever possible.     

A 22-year course of the Kay-Shiley disc valve with muscle guard at the mitral position.

Almost 33 years have elapsed since the introduction of the Kay-Shiley disc valve in Japan. Following the development of pyrolite carbon, the Kay-Shiley valve is no longer in clinical use. We report the case of a female patient who had had an isolated mitral valve replacement with the Kay-Shiley disc valve with single muscle guard 22 years previously. After numerous thromboembolic episodes with the Kay-Shiley disc valve, a successful reoperation was done with the CarboMedics valve. The explanted valve revealed that the grooved occluder disc had a loosely adherent clot. The thromboembolism is a notorious complication associated with this valve. We recommend re-replacement of the Kay-Shiley valve whenever possible.     

The elimination of periprosthetic leaks as a complication of mitral valve replacement

A technique for placement of a mitral valve prosthesis has been designed specifically to eliminate the development of periprosthetic leak as a complication of mitral valve replacement. This technique has been employed in 97 patients undergoing isolated mitral valve replacement. No incidents of periprosthetic leak have been discovered in this group, despite a careful search for the complication.This group of patients is compared to an earlier group in whom mitral valve replacement was performed using more common techniques. A 10% incidence of periprosthetic leak was found in this group. Periprosthetic leaks commonly cause severe congestive heart failure or pronounced anemia from excessive hemolysis. Reoperation for the repair of periprosthetic leaks has been associated with a high mortality. These leaks are regarded as a technical error and may be avoided by an appropriate change in the technique of mitral prosthesis insertion.     

Mitral stenosis caused by an amplatzer occluder device used to treat a paravalvular leak

Paravalvular leaks following valve replacement can result in heart failure and hemolysis. Surgical intervention is the treatment of choice, but it carries substantial risk of morbidity and mortality. Percutaneous techniques using devices designed for congenital heart disease are increasingly applied to the treatment of paravalvular leaks. We present the case of a mitral paravalvular leak treated with an Amplatzer occluder device. Unfortunately, the device occluded flow through the mitral valve, resulting in symptomatic mitral stenosis requiring surgical intervention.     

Surgical management of embolized Amplatzer septal occluder into the left ventricle tangled with the mitral valve

Device embolization is a rare major complication of atrial septal defect percutaneous closures which requires surgical management if noninvasive retrieval fails. We report a symptomatic delayed embolization of an Amplatzer septal occluder device into the left ventricle outflow tract tangled with the mitral valve, complicated with ventricular arrhythmias and cardiac tamponade during percutaneous retrieval attempt. Emergent surgical treatment was performed, requiring a combined approach through the right atrium and the aorta for surgical removal.     

A case of emergency surgery for acute mitral regurgitation due to complete papillary muscle rupture as complication of acute inferior myocardial infarction

We experienced a case with acute mitral regurgitation caused by complete posterior papillary muscle rupture as complication of acute inferior myocardial infarction, who underwent successfully emergency operation of mital valve replacement and coronary revascularization in acute stage. A 64-year-old woman developed sudden cardiogenic shock shortly after the onset of acute inferior myocardial infarction. The diagnosis of acute inferior myocardial infarction was based on the electrocardiographic findings. Under IABP support, preoperative coronary angiography visualized total occlusion of segment 3 of the right coronary artery, and preoperative left ventriculography showed akinesis of inferior wall and severe mitral regurgitation. At 6 hours after onset of papillary muscle rupture, emergency operation was performed. At operation, posterior papillary muscle was found to be totally ruptured. Coronary artery revascularization and mitral valve replacement were performed. Postoperative course was uneventful, with 4 days of IABP and 5 days of ventilatory support. She was discharged on the twentieth postoperative day in NYHA class I. Reports of successful emergency operation for total papillary muscle rupture following acute myocardial infarction are rare. Early diagnosis and surgical treatment are mandatory to save this group of patients.     

Mitral regurgitation secondary to anterior leaflet rupture during percutaneous balloon valvuloplasty: case report

Rheumatoid heart disease and the mitral stenosis secondary to it in the long term are still important cardiovascular problems in developing countries. Percutaneous balloon mitral valvuloplasty is a valid treatment option with low complication rates for relieving the signs and symptoms of selected patients with mitral valve stenosis. In this report, we describe subacute mitral regurgitation secondary to anterior leaflet rupture following percutaneous balloon mitral valvuloplasty and the management strategy in a 54-year-old female patient. Such a complication is rare in experienced hands in the current era.     

A case of acute extrinsic malfunction of prosthetic valve due to suture tag causing incomplete closure of the disc]

A 56-year-old woman who had suffered from both aortic and mitral valve stenosis and regurgitation was treated by replacement of valves with 23 mm and 27 mm Bj?rk-Shiley valves respectively. After weaning from cardiopulmonary bypass, the arterial systolic pressure rose to 100 mmHg but the diastolic pressure fell to 40 to 50 mmHg. Studies including transesophageal echocardiogram and fluoroscopy during operation revealed the valves functioning normally. Because low diastolic pressure and low cardiac output continued during postoperative period, fluoroscopy was carried out again. It showed incomplete diastolic closure of the disc of the prosthetic aortic valve. The emergency operation was performed. At reoperation, it was found that one of the end of suture knots located between the valve ring and the disc prevented the occluder from seating completely and caused aortic regurgitation. The suture end was cut shorter and the prosthesis within the sewing ring was rotated so that the occluder was kept away from the suture end.     

Delayed rupture of the left ventricle after mitral valve replacement with bioprosthesis.

Rupture of the posterior ventricular wall after mitral valve replacement is a complication rarely reported in the literature. Perforation of the left ventricle after mitral valve replacement with a bioprosthesis has been described in only 3 patients. We have had 2 patients with this complication out of 322 patients who had mitral valve replacement with bioprosthesis. These perforations were caused by impingement of the posterior strut of the bioprosthesis on the posterior left ventricular wall, with intramyocardial hematoma and delayed rupture of the left ventricle.     

二尖瓣替换术后9例左室破裂

二尖瓣替换术后左室破裂属少见而死亡率极高的并发症。阜外医院自１９７６年５月至１９９１年１０月行二尖瓣替换（ＭＶＲ）或合并其它手术共２０７５例，其中左室破裂９例，发生率为０．４３％（９／２０７５）；抢救成功３例。预防措施包括：（１）避免心脏受到各种机械性损伤；（２）保留左室生理结构环的完整性；（３）术中、术后早期心肌保护措施得当。     

Rupture of the posterior wall of the left ventricle after mitral valve replacement: etiological and technical considerations

Rupture of the posterior wall of the left ventricle after mitral valve replacement, although infrequent, may be a highly lethal complication. Controversy exists regarding the etiology of this complication. Suggested causative factors include the type and extent of the valvular disease, type and size of the prosthesis, and the surgical techniques used. Our experience over a 20-year period includes 10 patients with rupture of the left ventricle following mitral valve replacement. In all patients, both mitral leaflets were excised together with the attached chordae. Three patients survived after repair of the rupture. Repair consisted of compressing the area between the left atrium and the base of the papillary muscle using two strips of Teflon and deep mattress sutures passed beneath the coronary vessels in the atrioventricular groove. Since 1983 we have routinely preserved the posterior leaflet of the mitral valve with its attached chordae to maintain a "tethered loop" between the mitral valve and ventricle. No further ruptures have occurred. The technique used for repair represents reconstitution of the divided loop between the ventricle and the mitral valve.     

A technique to repair type I left ventricular rupture following mitral valve replacement

Rupture of the posterior left ventricle is a serious complication following mitral valve replacement. A successful method of repair is illustrated. The causes, other methods of repair, and means to prevent this complication are discussed.