Surgical Redo in Mitral Valve for Multiple Prosthetic Dysfunctions: Case Report

Abstract

: Introduction: Valve-in-valve (v-in-v) implantation has become common in recent years. However, complications may occur such as paravalvular leak, infective endocarditis or even deinsertion of the prosthesis. We describe a rare case of a mitral bioprosthesis displacement towards the left atrium three years after a second v-in-v.

Case report: A 56-year-old man was admitted to the emergency department due to decompensated heart failure profile B. He had a history of liver disease and multiple mitral valve replacements (1985, 2005 and 2011), in addition to v-in-v in 2020, and again in 2021 (due to thrombosis of the implanted mitral prosthesis) On physical examination there was an irregular heart rhythm, holosystolic murmur 4+/6+ in mitral focus, crackles in pulmonary bases, ascites and edema of the lower limbs 2+/4+. Transesophageal echocardiography (TEE) showed left ventricle ejection fraction of 67%, mitral bioprosthesis displaced towards the atrium, with partial dehiscence and significant paraprosthetic leak (Figure 1), associated with left atrium to left ventricule peak gradient = 28 mmHg, and mean gradient = 7 mmHg (Figure 2). Besides, a significant insufficiency and pulmonary artery systolic pressure estimated at 105 mmHg were observed. The patient progressed to clinical worsening and cardiogenic shock. Despite the high surgical risk (Euroscore II = 14), a “salvage” mitral prosthesis redo surgery was performed, with implantation of a new mitral bioprosthesis and tricuspid valve repair. No signs of infective endocarditis was seen on the anatomopathological analysis, and the patient was discharged with significant clinical improvement. Conclusions: Patients with mitral stent grafts may have early or late complications. Careful clinical and echocardiographic follow-up, associated with immediate surgical intervention, allowed the patient's good clinical evolution.