Regurgitant flow of mitral valve prostheses: an intraoperative transesophageal echocardiographic study.

To assess the regurgitant characteristics of mitral biologic and mechanical prostheses immediately after implantation, intraoperative transesophageal echocardiography was performed in 27 patients, aged 32 to 69 years, undergoing open-heart surgery for rheumatic heart disease (n = 19), mitral valve prolapse (n = 3), malfunctioning prostheses (n = 3), or periprosthetic leaks (n = 2). The prostheses included 13 biologic (Carpentier-Edwards) and 14 mechanical valves (five Starr-Edwards, five Medtronic-Hall, and four Bjork-Shiley). Physiologic transvalvular regurgitant flow was detected in both biologic and mechanical prostheses. The spatial extent of the regurgitant jets was usually greater in the mechanical than in the biologic valves, and systolic jets, characteristic of each type of valve, were visualized consistently. Trivial periprosthetic jets (PPJs) were observed in many implanted valves (14/27). The median maximal jet area was 0.46 cm2 (range 0.1 to 1.5 cm2). Cardiopulmonary bypass was reinstituted in two patients. In one patient a PPJ was judged extensive enough (area 3.6 cm2) to warrant surgical revision of the implant, but no dehiscence was found. In the other patient a turbulent PPJ (area 5.5 cm2) was associated with a 0.5 cm dehiscence at the surgical inspection. In conclusion, (1) all mitral prostheses exhibit physiologic transvalvular regurgitation, (2) trivial mitral PPJ is a common finding in newly implanted mitral valves and does not require the revision of the implant, and (3) further experience based on larger series of patients is required to determine the maximal acceptable size of a mitral PPJ detected by intraoperative transesophageal echocardiography.

Extracardiac left to right shunt in a patient with biventricular postinfarction rupture and pseudoaneurysm.

A 68 year old man had a diaphragmatic myocardial infarction and 9 months later was admitted with severe congestive heart failure (functional class IV). Cardiac catheterization demonstrated a postinfarction pseudoaneurysm. Because of a massive left to right shunt (pulmonary to systemic flow ratio = 2.7), concomitant rupture of the ventricular septum was suspected. At surgery the pseudoaneurysm communicated with the right ventricle through two different orifices and with the left ventricle through another ostium. The ventricular septum was intact. Therefore, the shunt was extracardiac through the pseudoaneurysm (left ventricle----pseudoaneurysm----right ventricle). The unique combination of lesions allowed the patient to survive. The false aneurysm was excised and primary repair was performed in the orifices of the right and left ventricular walls. The postoperative course was uneventful and 10 months later the patient was in functional class I.