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CARDIOVASCULAR ANESTHESIOLOGY

Diastolic Regurgitation Through a Bi-Leaflet Mechanical Valve in the Mitral Position

From the Department of Anesthesiology and Pain Medicine, University of California, Davis, California.

Address correspondence and reprint requests to Mojca Remskar Konia, MD, Department of Anesthesiology and Pain Medicine, University of California Davis Health System, 4150 v. St., Suite 1200, Sacramento, CA 95817. Address e-mail to mojca.konia{at}ucdmc.ucdavis.edu.

A 64-yr-old man presented for aortic valve replacement due to worsening aortic insufficiency (AI) associated with left ventricular (LV) dilation. He had a history of mitral valve replacement with a bi-leaflet mechanical St. Jude’s valve 15 yr before this surgery. Preoperative transthoracic echocardiography showed 3–4+ AI and mitral regurgitation (MR) estimated to be 3+. The ejection fraction was assessed as 60%. Cardiac catheterization demonstrated no significant coronary artery disease, AI 3–4+, MR 1+ and an ejection fraction of 40%.

Aortic valve replacement with possible aortic root replacement was planned. An intraoperative precardiopulmonary bypass transesophageal echocardiogram was requested by the surgeon to examine the mechanical mitral valve for signs of significant regurgitation requiring surgical treatment.

During intraoperative transesophageal echocardiogram, the aortic valve was evaluated in the midesophageal aortic valve short-axis view and midesophageal aortic valve long-axis view. The right and noncoronary cusp of the aortic valve were thin and stretched and were prolapsing into the LV outflow tract. Central edges of the leaflets were thickened and mildly retracted with focal areas of calcification. The AI jet was eccentric, directed towards and under the mitral valve leaflets. It was estimated as 3–4+ based on over 6 mm width of the vena contracta, AI height/LV outflow tract diameter ratio of 70% and holosystolic retrograde flow in the descending aorta.

The bi-leaflet prosthetic mitral valve leaflets could be well visualized in the midesophageal four-chamber view and appeared to be moving well and symmetrically. Color Doppler examination of the mitral valve in different midesophageal views demonstrated MR estimated as 1–2+. On careful examination, we were able to distinguish systolic regurgitant jets consistent with expected mechanical valve backflow (washing jets) (Fig. 1, Video clip 1; please see video clip available at www.anesthesia-analgesia.org) and a separate diastolic mechanical valve regurgitant jet. The diastolic jet appeared to be related to the eccentric jet of AI (Fig. 2, Video clip 1). No paravalvular leaks were noted. Aortic root replacement using a 27 mm St. Jude valve graft conduit with mechanical valve was performed.

View larger version (35K): [in this window] [in a new window]   Figure 1. Midesophageal long-axis view with color Doppler showing the systolic regurgitant jet through a bi-leaflet mechanical mitral valve. Arrow points at the regurgitant jet. Long vertical blue line in the electrocardiogram tracing marks the time point during systole at which the still image was obtained. LA = left atrium; LV = left ventricle; Ao = ascending aorta.

View larger version (41K): [in this window] [in a new window]   Figure 2. Midesophageal long-axis view with color Doppler demonstrating the diastolic regurgitant jet through a bi-leaflet mechanical mitral valve. Arrow points at the regurgitant jet. Long vertical blue line in the electrocardiogram tracing marks the time point during diastole at which the still image was obtained. LA = left atrium; LV = left ventricle; Ao = ascending aorta.

Transesophageal echocardiography after aortic root and valve replacement demonstrated good function of the mechanical valve in the aortic position with backflow jets. The bi-leaflet mechanical valve in the mitral position was re-examined after surgery and showed only backflow systolic jets (Video clip 2). The diastolic jet, observed before aortic valve replacement, had completely disappeared.

DISCUSSION

Diastolic MR has been described with native mitral valves.1 It can be best documented with continuous wave Doppler spectral display. Most often it has been shown to be related to poor LV function and regional mechanical dyssynchrony with atrio-ventricular block of different grades.2 It is important to recognize diastolic MR in patients with poor LV function and atrio-ventricular dyssynchrony in whom resynchronization may decrease LV pressure and increase cardiac output.3,4

Diastolic MR has also been described in patients with a significant increase of LV end-diastolic filling pressure, in the presence of restrictive ventricular hemodynamics or severe AI, when a regurgitant jet may cause native mitral valve leaflet dysfunction.5

We have not found any report of diastolic regurgitation of a mechanical valve in the mitral position. In our patient, the diastolic regurgitant jet of the bi-leaflet mechanical valve appeared associated with an eccentric jet of severe AI that was directed towards the mechanical mitral valve leaflets (Fig. 2, Video clip 1). We hypothesized that, due to the anatomic orientation of the bi-leaflet mechanical valve, in which the two major orifices are aligned with the anterior and posterior leaflet commissures, the anterior leaflet is acting as a reflector and had redirected the aortic regurgitant jet into the left atrium. The diastolic MR may also be explained by the jet of AI impeding expected closure of the mechanical leaflet when the LV diastolic pressure exceeds the left atrium pressure. Our hypothesis of AI being responsible for diastolic MR was supported by the disappearance of diastolic MR after the aortic valve was replaced. In our case, the magnitude of MR observed was not enough to warrant replacement of the mechanical mitral valve for hemodynamic reasons. However, it was significant enough to potentially suggest a malfunction of the mechanical valve if its relation to the jet of AI had not been recognized, which could have prompted its replacement. Thus, recognizing this relation to AI avoided an unnecessary surgical procedure.

Footnotes

This article has supplementary material on the Web site: www.anesthesia-analgesia.org.

Accepted for publication May 7, 2008.

REFERENCES

1. Sochanski M, Lang RM, Weinert L, Bednarz J, Neumann A, Ehler D, David D. Hemodynamic prerequisites for the occurrence of diastolic mitral valve regurgitation. Am J Cardiol 1993;71:1470–3[Web of Science][Medline]
2. Panidis IP, Ross J, Munley B, Nestico P, Mintz. Diastolic mitral regurgitation in patients with atrioventricular conduction abnormalities: a common finding by Doppler echocardiography. J Am Coll Cardiol 1986;7:768–74[Abstract]
3. Kanzaki H, Bazaz R, Schwartzman D, Dohi K, Sade LE, Gorcsan J III. A mechanism for immediate reduction in mitral regurgitation after cardiac resynchronization therapy: insights from mechanical activation strain mapping. J Am Coll Cardiol 2004;44:1619–25[Abstract/Free Full Text]
4. Lancellotti P, Melon P, Sakalihasan N, Waleffe A, Dubois C, Bertholet M, Pierard LA. Effects of cardiac resynchronization therapy on functional mitral regurgitation in heart failure. Am J Cardiol 2004;94:1462–5[Web of Science][Medline]
5. Agmon Y, Freeman WK, Oh JK, Seward JB. Diastolic mitral regurgitation. Circulation 1999;99:e13[Medline]

This Article Full Text (PDF) CME: Take the course for this article: Echo Rounds Echo Loops Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in Web of Science Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Konia, M. R. Articles by Uppington, J. Search for Related Content PubMed PubMed Citation Articles by Konia, M. R. Articles by Uppington, J. Related Collections Cardiovascular Heart Monitoring (Cardiac) Echo Rounds Video Clip