Dehiscence of Mitral Annuloplasty Ring
A 58-year-old man came to the emergency department with chest pain and progressive shortness of air of &12 hours’ duration. The patient was in his usual state of health until 3 days before the present admission, at which time he noted intermittent angina, progressive fatigue, dyspnea on exertion, and orthopnea. He had undergone 3-vessel CABG 11 years earlier and the placement of a mitral annuloplasty ring 18 months previously because of severe ischemic mitral regurgitation. Physical examination revealed elevated jugular venous pressure; irregular pulse; brisk, low-volume carotid upstrokes; cardiomegaly; muffled S1; prominent P2; S3 gallop; apical holosystolic blowing murmur radiating to the back; mild hepatomegaly; and 2+ pitting edema in both lower extremities. The ECG showed atrial flutter at a rate of 127 bpm and new Q waves in the inferior leads compared with the ECG recorded 2 weeks previously at his primary physician’s office. Cardiac enzymes were elevated, with a downward trend. The chest radiograph showed left atrial enlargement, enlarged cardiac silhouette, and evidence of pulmonary venous congestion. Transesophageal echocardiography demonstrated a dilated mitral annulus, extensive inferolateral dehiscence of the mitral annuloplasty ring (Figure 1), papillary muscle dysfunction with discoaptation of the mitral valve leaflets, and severe mitral regurgitation with an eccentric inferolaterally directed jet (Figure 2 and Data Supplement Movie Clip). Left ventricular ejection fraction was estimated at 35%. Cardiac catheterization revealed severe native 3-vessel disease with 2 of the 3 bypass grafts patent. The saphenous vein graft to the posterior descending coronary artery was occluded at the distal anastomosis site. The native mitral valve was replaced with a mechanical prosthesis. Intraoperative transesophageal echocardiography and postoperative transthoracic echocardiography confirmed no residual mitral regurgitation. The patient recovered uneventfully.
The online-only Data Supplement can be found at http://circ.ahajournals.org/cgi/content/full/112/18/e305/DC1.