Intraoperative Precise Localization of Paravalvular Mitral Leak by a Simple Surgical Maneuver
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c 2008 Wiley Periodicals, Inc. 541 Intraoperative Precise Localization of Paravalvular Mitral Leak by a Simple Surgical Maneuver Idris Ali, M.D., F.R.C.S.C. Cardiovascular Surgery, QEII Health Science Centre, Canada ABSTRACT Paravalvular leak after mitral valve replacement is a known surgical problem. 1 Its management is controversial and challenging. The first and the most important step is to localize the leaking spot precisely. Echocardiogram is the standard technique that is used to localize the leak. 2,3 The echocardiogram is accurate most of the time; however, in some occasions it does not easily provide the exact orientation of the leaking areas. A simple operative maneuver, which was used to allow the surgeon to localize the leak visually, and have accurate and solid repair, is described below. doi: 10.1111/j.1540-8191.2008.00609.x (J Card Surg 2008;23:541-542) Paraprosthetic valvular leakage is a known compli- cation that occurs in 2% to 17% of cases. 4 Infection, annular calcification, suture fracture, and size of the prostheses, are some factors that can lead to such a problem. 5 Surgical or interventional catheter based treatment is indicated in most of the cases. The first step in the process of repairing the leakage is to de- tect its site precisely. Transthoracic echocardiography (TEE) is the standard technique in localizing the leaking spots 2,6 ; however, in some cases the TEE is unable to determine the exact orientation of the defective re- gion. This paper describes a simple surgical maneuver that enables the surgeon to visualize the leaking sites directly, leading to a precise and solid repair. METHOD The best way to localize the leak is to visualize it while the heart is beating and ejecting. This is done while the heart is on cardiopulmonary bypass. The aorta is clamped, and blood from the pump at 37 ◦ C with no potassium is infused in the cardioplegia line. This will keep the heart beating, and the aortic clamp will pre- vent any air from entering the systemic circulation. The left atrium is opened, and the pulmonary venous return is controlled with suction. The leak is well seen, with each ejection from the left ventricle, around the valve ring. The degree of ejection is adjusted by controlling the amount of blood entering the left ventricle. This is done by allowing either more blood flow from the pul- monary veins through the mitral valve, or blood flow from the aorta through the aortic valve by distorting the aortic valve annulus with external pressure. Intraopera- tively, the echocardiogram was done by certified expe- Address for correspondence: Idris Ali, M.D., F.R.C.S.C., Cardiovascular Surgery, QEII Health Science Centre, 2265–1796 Summer Street, Hali- fax, N. S., B3 H 2A7 Canada. Fax: 902-473-4448; e-mail: [email protected] rienced echo-cardiographers. The technique was tried in nine cases (three cases of redo chronic leaks and six cases of acute leaks detected by echocardiogram intraoperatively during first time valve replacement). RESULTS The echocardiogram was accurate and precise in lo- calizing the leaking in three cases. The exact localization and orientation of the leak was not accurate in the re- maining six cases. The leak was detected visually dur- ing the ejection of the ventricle in all cases and then repaired. The tissue defects under the prosthetic ring at which the leak was happening were not easily seen during the absence of the ejection except in one case. COMMENTS The most common nonstructural dysfunction after valve replacement is the paraprosthetic leak. The re- pair of the paravalvular leak is indicated in the patients with severe symptoms and when there is hemolysis. This represents about 40% of the total patients with an echocardiographic diagnosis of paraprosthetic regurgi- tation. 6 The technique that we described allows the surgeon to locate the defective areas even in the dif- ficult spots around the valve and under the prosthetic ring. The inaccuracy of the echocardiogram in detecting the exact orientation of the leaking spots in the six cases of this series indicates the importance of having an adjunctive method to help in localizing the defective areas. Having the ventricle in an ejecting state as in the described technique is an essential step in making the leaks obvious and easy to spot. In conclusion, the described controlled ejecting left ventricle technique can be considered as an additional simple tool in mitral valve surgery.
Transcript of Intraoperative Precise Localization of Paravalvular Mitral Leak by a Simple Surgical Maneuver
c© 2008 Wiley Periodicals, Inc. 541
Intraoperative Precise Localization ofParavalvular Mitral Leak by a SimpleSurgical ManeuverIdris Ali, M.D., F.R.C.S.C.
Cardiovascular Surgery, QEII Health Science Centre, Canada
ABSTRACT Paravalvular leak after mitral valve replacement is a known surgical problem.1 Its management is
controversial and challenging. The first and the most important step is to localize the leaking spot precisely.
Echocardiogram is the standard technique that is used to localize the leak.2,3 The echocardiogram is accurate
most of the time; however, in some occasions it does not easily provide the exact orientation of the leaking
areas. A simple operative maneuver, which was used to allow the surgeon to localize the leak visually, and
have accurate and solid repair, is described below. doi: 10.1111/j.1540-8191.2008.00609.x (J Card Surg2008;23:541-542)
Paraprosthetic valvular leakage is a known compli-cation that occurs in 2% to 17% of cases.4 Infection,annular calcification, suture fracture, and size of theprostheses, are some factors that can lead to sucha problem.5 Surgical or interventional catheter basedtreatment is indicated in most of the cases. The firststep in the process of repairing the leakage is to de-tect its site precisely. Transthoracic echocardiography(TEE) is the standard technique in localizing the leakingspots2,6; however, in some cases the TEE is unableto determine the exact orientation of the defective re-gion. This paper describes a simple surgical maneuverthat enables the surgeon to visualize the leaking sitesdirectly, leading to a precise and solid repair.
METHOD
The best way to localize the leak is to visualize it whilethe heart is beating and ejecting. This is done whilethe heart is on cardiopulmonary bypass. The aorta isclamped, and blood from the pump at 37 ◦C with nopotassium is infused in the cardioplegia line. This willkeep the heart beating, and the aortic clamp will pre-vent any air from entering the systemic circulation. Theleft atrium is opened, and the pulmonary venous returnis controlled with suction. The leak is well seen, witheach ejection from the left ventricle, around the valvering. The degree of ejection is adjusted by controllingthe amount of blood entering the left ventricle. This isdone by allowing either more blood flow from the pul-monary veins through the mitral valve, or blood flowfrom the aorta through the aortic valve by distorting theaortic valve annulus with external pressure. Intraopera-tively, the echocardiogram was done by certified expe-
Address for correspondence: Idris Ali, M.D., F.R.C.S.C., CardiovascularSurgery, QEII Health Science Centre, 2265–1796 Summer Street, Hali-fax, N. S., B3 H 2A7 Canada. Fax: 902-473-4448; e-mail: [email protected]
rienced echo-cardiographers. The technique was triedin nine cases (three cases of redo chronic leaks andsix cases of acute leaks detected by echocardiogramintraoperatively during first time valve replacement).
RESULTS
The echocardiogram was accurate and precise in lo-calizing the leaking in three cases. The exact localizationand orientation of the leak was not accurate in the re-maining six cases. The leak was detected visually dur-ing the ejection of the ventricle in all cases and thenrepaired. The tissue defects under the prosthetic ringat which the leak was happening were not easily seenduring the absence of the ejection except in one case.
COMMENTS
The most common nonstructural dysfunction aftervalve replacement is the paraprosthetic leak. The re-pair of the paravalvular leak is indicated in the patientswith severe symptoms and when there is hemolysis.This represents about 40% of the total patients with anechocardiographic diagnosis of paraprosthetic regurgi-tation.6 The technique that we described allows thesurgeon to locate the defective areas even in the dif-ficult spots around the valve and under the prostheticring.
The inaccuracy of the echocardiogram in detectingthe exact orientation of the leaking spots in the sixcases of this series indicates the importance of havingan adjunctive method to help in localizing the defectiveareas. Having the ventricle in an ejecting state as in thedescribed technique is an essential step in making theleaks obvious and easy to spot.
In conclusion, the described controlled ejecting leftventricle technique can be considered as an additionalsimple tool in mitral valve surgery.
542 ALIPRECISE LOCALIZATION OF PARAVALVULAR MITRAL LEAK
J CARD SURG2008;23:541-542
REFERENCES
1. Moneta A, Villa E, Donatell F: An alternative technique fornon-infective paraprosthetic leakage repair. Eur J Cardio-thorac Surg 2003;23:1074-1075.
2. Movsowitz H, Shah SI, Ioli A, et al: Long-term follow-upof mitral paraprosthetic regurgitation by transesophagealechocardiography. J Am Soc Echocardiogr 1994;7:488-492.
3. Formolo JM, Reyes P: Refractory hemolytic anemia sec-ondary to perivalvular leak diagnosed by transesophagealechocardiography. J Clin Ultrasound 1995;23:185-188.
4. Hammermeistter K, Sethi GK, Henderson WG, et al: Out-comes 15 years after valve replacement with a mechanicalversus bioprosthetic valve: Final report of the Veterans Af-fairs randomized trial. J Am Coll Cardiol 2000:36(4):1152-1158.
5. Dhasmann JP, Blackstone EH, Kirklin JW, et al: Factorsassociated with periproathetic leakage following primarymitral valve replacement with special consideration of thesuture technique. Ann Thorac Surg 1983;35(2):170-178.
6. Genoni M, Franzen D, Vogt P, et al: Paravalvular leakageafter mitral valve replacement: Improved long-term sur-vival with aggressive surgery? Eur J Cardiothorac Surg2000;17(1):14-19.
