Asymptomatic Rupture of the Left Ventricle
We present the case of an asymptomatic, 75-year-old female in whom perforation of the left ventricle and formation of a pseudoaneurysm was found on transesophageal echocardiography 2 months after mitral valve replacement.
Patient history showed a mitral valve reconstruction with ring implantation 16 years ago. She developed severe mitral valve regurgitation, and mitral valve replacement was performed. A mitral bioprosthesis (St. Jude Medical, Epic 29) was implanted successfully. During surgery, it was difficult to remove the annuloplasty ring. The annulus itself was very brittle. The pledged sutures were placed in the ventricle to address this issue. The postoperative course was uneventful, and transthoracic echocardiographic examination at discharge did not reveal any pathologies (Figure 1; Movie I in the online-only Data Supplement). Two months later, she was admitted to the hospital because of a new onset of atrial fibrillation. On transthoracic echocardiographic examination, we found a normally functioning mitral valve prosthesis (mean pressure gradient, 5 mm Hg; mitral valve area, 2.9 cm2). The left ventricle was normal, with good global and regional systolic function; however, in the parasternal long-axis view, a round, hypoechoic space could be seen below the mitral valve ring (Figure 2; Movie II in the online-only Data Supplement). On transesophageal echocardiography performed before cardioversion, a hypoechogenic space located between the anterior wall of the left ventricle and the left atrial appendage was found (Figure 3; Movie III in the online-only Data Supplement). The color Doppler examination disclosed the presence of flow inside this space (Figures 4 and 5; Movies IV and V in the online-only Data Supplement). Using a modified midesophageal view at 132°, the longitudinal shape of this structure could be recognized (Figure 6; Movie VI in the online-only Data Supplement). Three-dimensional echocardiography disclosed a longitudinal cavity of a pseudoaneurysm along the posterior mitral annulus (Figure 7; Movie VII in the online-only Data Supplement). The rupture of the left ventricle, a pseudoaneurysm entry was localized directly under the prosthetic valve ring (Figure 8; Movie VIII in the online-only Data Supplement). The rupture of the left ventricle (a pseudoaneurysm entry) was localized directly under the prosthetic valve ring ((Figure 8; Movie VIII in the online-only Data Supplement). The injection of echocardiographic contrast (SonoVue, Bracco Diagnostics, Princeton, NJ) caused an immediate opacification of the aneurysm cavity (Figure 9; Movie IX in the online-only Data Supplement). The diagnosis was confirmed with nuclear magnetic resonance (Figures 10 and 11). The patient underwent urgent surgery. After explantation of the mitral prosthesis, the rupture of the left ventricle could be seen (Figure 12). The cavity of the pseudoaneurysm was filled with TachoSil (Takeda Pharmaceuticals International GmbH, Zurich, Switzerland), the rupture was closed with a bovine pericardial patch (Figure 13), and a new mitral prosthesis was reimplanted. The postoperative echocardiographic examination confirmed the successful closure of the pseudoaneurysm. The former cavity of the pseudoaneurysm could be seen as a hyperechogenic area (Figures 14 and 15; Movies X and XI in the online-only Data Supplement). The postoperative course was uneventful.
Rupture of the left ventricle, first reported by Roberts and Morrow in 1967,1 is an infrequent complication of mitral valve replacement but is associated with extremely high mortality, reaching 50% to 93% in some series.1–3 There are 5 types of rupture, according to the site. The most frequent is type I, as in the present case, in which the site of the rupture is located at the atrioventricular groove. Type II is localized at the base of the papillary muscle. Type III is located between type I and II. Types IV and V are uncommon, the first located at the lateral wall and the second at the posterior wall of the left ventricle.4 The tear can occur immediately in the operating room, being a cause of serious bleeding. Delayed tears can occur hours, days, or even years after valve implantation, usually presenting as pseudoaneurysms. Formation of the pseudoaneurysm in the present case was probably caused by the brittle annulus tissue. Many different operative techniques have been described to address this pathology; however, none has proved to be superior.4 In our opinion, the use of a bovine pericardial patch is the most effective technique.
The online-only Data Supplement is available with this article at http://circ.ahajournals.org/lookup/suppl/doi:10.1161/CIRCULATIONAHA.112.000782/-/DC1.
- © 2013 American Heart Association, Inc.