Iatrogenic Aortic Insufficiency Following Mitral Valve Replacement: Case Report and Review of the Literature

Abstract

We report a 28-year-old white female who suffered significant aortic insufficiency (AI) following mitral valve (MV) replacement for endocarditis. The patient had history of rheumatoid arthritis and presented to our emergency department with a 3-month history of dyspnea, orthopnea, fevers and weight loss, worsening over 2 weeks, for which she took intermittent acetaminophen. On admission, vital signs revealed blood pressure of 99/70 mm Hg, heart rate of 120 beats/minute, and temperature of 98.8 °F; her weight was 100 lbs. Physical exam revealed a thin and pale female. Cardiac auscultation revealed regular tachycardic rhythm with a third heart sound, and a short early systolic murmur at the left lower sternal border without radiation. Lungs revealed right lower lobe rhonchi. Initial pertinent laboratory evaluation revealed hemoglobin 9.6 g/dL and white blood cell count 17,500/μL. Renal function was normal, and hepatic enzymes were mildly elevated. Chest radiogram revealed right lower lobe infiltrate. Blood cultures revealed Enterococcus faecalis. Two-dimensional echocardiogram revealed large multilobed vegetation attached to the anterior MV leaflet with severe mitral regurgitation (MR), otherwise normal left ventricular systolic function. She was started on appropriate antibiotics and underwent MV replacement with 25-mm On-X prosthesis. She was noted post-operatively to have prominent systolic and diastolic murmurs. Repeat echocardiogram revealed normal mitral prosthesis function, with new moderately severe AI. Transesophageal echocardiogram revealed AI originating from a tethered non-coronary cusp, due to a suture preventing proper cusp mobility. The patient declined further surgery. She recovered slowly and was discharged to inpatient rehabilitation 4 weeks later. This case highlights the importance of vigilance to this potential serious complication of valve surgery with regard to diagnosis and treatment to prevent long-term adverse consequences.

A rare complication of mitral valve replacement: Iatrogenic aortic valve perforation

“…In the available literature till 2015, only 15 cases of iatrogenic aortic valve perforation after mitral valve surgery were reported . In 2016, three more cases were reported .…”

Iatrogenic Aortic Valve Perforation after Ventricular Septal Defect Repair

“…1,2) AV perforation after VSDR is rare and mostly studied as the case reports. [4][5][6][7] We report three consecutive patients who suffered significant aortic leaflet injury in the noncoronary leaflet during VSDR procedure and referred for reoperation in our institution.…”

“…1,2) Iatrogenic aortic valve (AV) perforation during non-aortic cardiac operations is a rare complication. The suture-related inadvertent injury to an AV leaflet can produce leaflet perforation with aortic regurgitation (AR) after ventricular septal defect repair (VSDR).…”

Third time mitral valve replacement-lessons learned

“…The mitral annulus has been described as a tissue plane at the confluence of surrounding structures rather than a distinctive anatomical entity . Injuries to the adjacent structures such as the aortic valve or LCX artery are well‐documented complications during MVR . Similarly, the potential for LVOT obstruction by a bioprosthesis strut in the mitral position has been described .…”