Iatrogenic aortic insufficiency following mitral valve replacement: case report and review of the literature

Abstract

We report a 28-year-old white female who suffered significant aortic insufficiency (AI) following mitral valve (MV) replacement for endocarditis. The patient had history of rheumatoid arthritis and presented to our emergency department with a 3-month history of dyspnea, orthopnea, fevers and weight loss, worsening over 2 weeks, for which she took intermittent acetaminophen. On admission, vital signs revealed blood pressure of 99/70 mm Hg, heart rate of 120 beats/minute, and temperature of 98.8 °F; her weight was 100 lbs. Physical exam revealed a thin and pale female. Cardiac auscultation revealed regular tachycardic rhythm with a third heart sound, and a short early systolic murmur at the left lower sternal border without radiation. Lungs revealed right lower lobe rhonchi. Initial pertinent laboratory evaluation revealed hemoglobin 9.6 g/dL and white blood cell count 17,500/μL. Renal function was normal, and hepatic enzymes were mildly elevated. Chest radiogram revealed right lower lobe infiltrate. Blood cultures revealed Enterococcus faecalis. Two-dimensional echocardiogram revealed large multilobed vegetation attached to the anterior MV leaflet with severe mitral regurgitation (MR), otherwise normal left ventricular systolic function. She was started on appropriate antibiotics and underwent MV replacement with 25-mm On-X prosthesis. She was noted post-operatively to have prominent systolic and diastolic murmurs. Repeat echocardiogram revealed normal mitral prosthesis function, with new moderately severe AI. Transesophageal echocardiogram revealed AI originating from a tethered non-coronary cusp, due to a suture preventing proper cusp mobility. The patient declined further surgery. She recovered slowly and was discharged to inpatient rehabilitation 4 weeks later. This case highlights the importance of vigilance to this potential serious complication of valve surgery with regard to diagnosis and treatment to prevent long-term adverse consequences.

Keywords: Aortic valve; Endocarditis; Mitral valve; Surgical complication.

Figure 1

Two-D parasternal long axis echocardiographic view showing the mitral valve vegetation (a) and the severe mitral regurgitation using superimposed color flow Doppler (b).

Figure 2

Mid-esophageal TEE images showing a suture tethering the non-coronary cusp (a), and the resulting moderate-to-severe AI by color flow Doppler (b).

Figure 3

Schematic showing the central location of the aortic valve and the vulnerability of the cusps in relation to adjacent surgery. RCC: right coronary cusp; LCC: left coronary cusp; NCC: non-coronary cusp; TV: tricuspid valve; MV: mitral valve; PV: pulmonic valve; MPA: main pulmonary artery; LA: left atrium; RA: right atrium; IAS: interatrial septum.