Introduction: The aging population and advancements in medical therapies have led to an increase in elderly patients with mitral stenosis. Repairing mitral annular calcification in these patients can be challenging due to the fragile myocardium. Atrioventricular dissociation after mitral valve replacement is a rare but serious complication with high mortality rates.
Description: A 67-year-old man with a history of severe mitral valve regurgitation underwent mitral valve repair but experienced worsening symptoms. During surgery, the damaged ring was removed, and a tissue valve was implanted. Post-surgery, the patient developed hypotension, severe bradycardia, and bleeding from the incision site. An echocardiogram revealed a pulsatile flow in the left atrium, indicating a contained pseudoaneurysm. Emergency exploration revealed mitral valve dehiscence, a large defect, and extensive bleeding. Despite efforts to repair and stabilize the patient, he unfortunately died.
Discussion: Left ventricular rupture is often associated with factors such as heavily calcified mitral valve annulus, bacterial endocarditis, and surgical trauma. There are three main subtypes of left ventricular rupture: Type I located at the atrioventricular groove, Type II at the base of the papillary muscles, and Type III between Types I and II.
Symptoms of left ventricular rupture can include unstable hemodynamics, failure to wean off cardiac bypass, major bleeding, ventricular arrhythmias, hypotension, and left ventricular failure. Doppler color flow echocardiography is used to detect extravasation along the posterolateral wall of the left ventricle. Left ventriculography may also be performed before discharge.
Repairing a left ventricular rupture after mitral valve replacement can be challenging due to factors such as friable ventricular myocardium, poor visualization, and the difficulty of suturing through the ventricular wall. Two main approaches to repair the rupture are the external and internal methods, with the internal approach considered safer and more successful. To prevent left ventricular perforation, certain considerations are taken, such as preserving posterior mitral valve chordae, minimizing excision of calcium, accurate sizing of the valve, and limited papillary muscle excision.
