Leaflet Fracture of a St. Jude Mechanical Bileaflet Valve
Eighteen months after mitral (33-mm St. Jude Medical) and aortic (25-mm Carbomedics Tophat) valve replacement because of rheumatic valve disease, a 54-year-old man was admitted with acute pulmonary edema. He had been in excellent condition until the sudden onset of epigastric pain and shortness of breath 2 hours before admission. Other than warfarin (International Normalized Ratio 2.7, 9 days before admission), he was not using any medication. Physical examination demonstrated a man in severe respiratory distress (blood pressure 95/60 mm Hg, temperature 36.2°C), and bilateral rales were heard. Heart sounds could not be detected. The ECG demonstrated sinus tachycardia (100/min) without signs of ischemia. The chest x-ray film showed bilateral pulmonary edema. After intubation and mechanical ventilation, a transesophageal echocardiogram was performed (Figure 1), revealing massive mitral regurgitation attributed to malfunctioning of one leaflet (Movies I, II, and III). The left ventricle was hyperdynamic. The patient was urgently transported to a thorax center (St. Antonius Hospital, Nieuwegein, the Netherlands). Although leaflet fracture was considered, mechanical valve thrombosis was considered more likely and thrombolytic therapy was initiated. On emergency surgery, which was performed because of progressive clinical deterioration, one leaflet of the mitral valve prosthesis was found to be broken, the major part missing (Figure 2). The valve was explanted and replaced by a 29-mm Carbomedics prosthesis. CT scanning localized the missing valve fragment in the right iliac artery bifurcation (Figure 3). This fragment was surgically removed 4 weeks later by a retroperitoneal approach. The patient made an uneventful recovery and returned to his professional life.
Movies I, II, and III are available in the online-only Data Supplement with this article at http://www.circulationaha.org.