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IMAGING VIGNETTE

Mechanisms of Mitral Valve DysfunctionFollowing Mitral Valve Repair forDegenerative Disease

Jocelyn N. Spoon, MD,* Vuyisile T. Nkomo, MD, MPH,* Rakesh M. Suri, MD, DPHIL,y Sorin V. Pislaru, MD, PHD,*Daniel B. Spoon, MD,* Hector I. Michelena, MD,* Maurice E. Sarano, MD,* Joseph F. Malouf, MD*

MITRAL VALVE REPAIR IS THE TREATMENT OF CHOICE FOR MITRAL REGURGITATION SECONDARY TO

myxomatous degenerative valve disease given the associated low operative mortality and excellent long-termsurvival. Recurrent mitral valve dysfunction requiring reoperation following primary valve repair is uncom-mon, especially when performed by experienced surgeons at high-volume centers. The most common etiologyof recurrent regurgitation after repair is progressive degeneration of the valvular apparatus, including newleaflet prolapse or flail. Less common mechanisms for repair failure can be categorized as procedural ortechnical failures and include annuloplasty dehiscence, leaflet suture rupture, incorrect artificial chord length,and incorrect annuloplasty position. Determining etiology of primary repair failure provides essential infor-mation regarding candidacy for re-repair, which is associated with superior outcomes over valve replacement(1). Our aim is to provide an echocardiography-based imaging guide to help evaluate patients presenting withrecurrent mitral valve dysfunction following repair. We have included 8 total illustrative cases (Figures 1 to 6).

Determination of the mechanism of mitral valve dysfunction following mitral valve repair is paramount andcan be done reliably with echocardiography. Two-dimensional and 3-dimensional transesophageal echocar-diography should be performed in all cases of recurrent mitral valve dysfunction because of superior spatialresolution and anatomic detail when compared with transthoracic echocardiography.

From the *Division of Cardiovascular Diseases and Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota; and the

yDivision of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota. Dr. Suri has received research funding from Sorin, Abbott,

Edwards Lifesciences, and St. Jude Medical; is a member of the board of Abbott (COAPT Trial Clinical Steering Committee) and St.

Jude Medical (Portico Trial Steering Committee); and is a consultant for Sorin (Perceval trial national principal investigator) and

Abbott (COAPT trial co-principal investigator). All other authors have reported that they have no relationships relevant to the

contents of this paper to disclose.

FIGURE 1 Progressive Degenerative Disease Causing New Leaflet Prolapse and Chordal Rupture

A 66-year-old man with dyspnea was diagnosed with bileaflet mitral valve prolapse and severe regurgitation. (A and B) Transesophageal echocardiogram (TEE) showed

redundant leaflets with severe, posteriorly directed regurgitation. During gross inspection, elongated anterior leaflet chordae were identified as the primary pathology

responsible for the regurgitation. (C and D) Successful repair was completed by insertion of 2 neochordae to the anterior leaflet and posterior annuloplasty band

insertion. (E and F) Two years later, the patient had recurrent dyspnea related to a newly ruptured chord (pink arrow) to the middle scallop (P2) of the posterior leaflet

(white arrow). (G) Three-dimensional TEE en-face view of the mitral valve confirmed intact prior repair and newly prolapsed P2 with ruptured chordae (asterisks). A 66-

year-old man with a ruptured chord (pink arrow) and flail P2 (yellow arrow) (H and I) underwent successful triangular resection and posterior annuloplasty band

insertion (J andK), but developed recurrent symptoms9 years later fromnewP2prolapse (L toN, yellow arrow). Usedwith permission from theMayo Clinic. AV¼ aortic valve;

LA ¼ left atrium; LV¼ left ventricle; RA¼ right atrium; RV¼ right ventricle.

Spoon et al. J A C C : C A R D I O V A S C U L A R I M A G I N G , V O L . 8 , N O . 1 0 , 2 0 1 5

Mechanisms of Mitral Valve Repair Failure O C T O B E R 2 0 1 5 : 1 2 2 3 – 7

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FIGURE 2 Early and Delayed Mitral Inflow Stenosis Following Mitral Valve Repair

A 71-year-old woman underwent mitral valve repair with a complete annuloplasty ring at an outside institution for a flail posterior leaflet (yellow arrow) from a ruptured

chord (pink arrow) (A and B). Over the next year, she experienced transient ischemic attacks. TEE showed large mobile thrombus (C, arrowheads) attached to the

annuloplasty ring associated with high-velocity inflow (D) and gradient (E) across the mitral valve. Endocarditis was ruled out. (F–H) Repeat TEE after chronic anti-

coagulation demonstrated near complete resolution of thrombus, but persistent obstruction from an undersized annuloplasty ring. A 62-year-old man status post 2

previous mitral valve repairs at an outside institution developed exertional dyspnea approximately 12 years following repair. (I and J) Transthoracic echocardiogram

apical 4-chamber depicted restricted leaflet motion and high-velocity mitral inflow and gradient. (K) Three-dimensional TEE en-face image of the mitral valve revealed

annuloplasty ring (double arrows) and thickened leaflets with a restrictive valve orifice (arrowhead). Used with permission from the Mayo Clinic. Ao ¼ aorta; other

abbreviations as in Figure 1.

J A C C : C A R D I O V A S C U L A R I M A G I N G , V O L . 8 , N O . 1 0 , 2 0 1 5 Spoon et al.O C T O B E R 2 0 1 5 : 1 2 2 3 – 7 Mechanisms of Mitral Valve Repair Failure

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FIGURE 3 Residual Mitral Regurgitation Secondary to Incomplete Initial Repair

A 78-year-old man underwent mitral valve repair for severe symptomatic regurgitation and aortic valve replacement for severe aortic valve regurgitation. Pre-bypass

mid-esophageal long-axis (A and B) and trans-gastric short-axis (C) views of the mitral valve suggested a flail leaflet (pink arrow) at the posteromedial commissure and

associated regurgitant jet. Gross surgical inspection of the valve revealed a flail A3 segment but otherwise normal-appearing valve. The repair involved chordae resection

and artificial chord placement in addition to posterior annuloplasty band insertion. Post-bypass TEE mid-esophageal (D and E) and transgastric (F and G) short-axis views

revealed persistent prolapse (arrowhead) with residual commissural regurgitation initially noted to be mild but progressed to at least moderate with continued imaging.

No repeat surgical intervention was performed given the difficult initial exposure of the mitral valve and presence of aortic valve prosthesis. Follow-up transthoracic

echocardiogram 3 years later confirmed progression to moderate–severe mitral regurgitation. Used with permission from the Mayo Clinic. AL ¼ anterior leaflet;

PL ¼ posterior leaflet; other abbreviations as in Figures 1 and 2.

FIGURE 4 Incorrect Neochord Length

A 63-year-old asymptomatic man with a history of mitral valve

prolapse status post–mitral valve repair at an outside institution

was found to have recurrent severe mitral regurgitation on

routine follow-up imaging prompting reoperation. (A and B) TEE

mid-esophageal 4-chamber view showed a redundant artificial

chord (pink arrow) attached to a prolapsed anterior leaflet

segment (yellow arrow) with severe posteriorly directed regur-

gitation. TEE transgastric short axis at the level of the mitral

valve (C) and with the probe pulled back to the level of the

gastroesophageal junction (D) revealed the site where the arti-

ficial chord had been attached (pink arrow) to the prolapsed A2/

A3 segment (yellow arrow). (E) Intraoperative photograph of the

anterior leaflet of the mitral valve depicted the redundancy in the

previously placed artificial chord, which had not been sized

correctly and thus did not appropriately support the prolapsed

segment and resulted in regurgitation. Used with permission

from the Mayo Clinic. Abbreviations as in Figures 1 and 3.

Spoon et al. J A C C : C A R D I O V A S C U L A R I M A G I N G , V O L . 8 , N O . 1 0 , 2 0 1 5

Mechanisms of Mitral Valve Repair Failure O C T O B E R 2 0 1 5 : 1 2 2 3 – 7

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FIGURE 5 Displacement of Annuloplasty Ring in Addition to Clip and

Leaflet Suture Dehiscence

A 63-year-old woman underwent a minimally invasive mitral repair involving

leaflet resection and sutureless annuloplasty ring placement secured with

nitinol clips at an outside institution. Significant mitral regurgitation

recurred 4 months later necessitating reoperation. (A) Intraoperative pre-

bypass TEE revealed 2 mitral regurgitant jets; (B and C) a regurgitant jet

outside the annuloplasty ring posteriorly (pink arrows), consistent with

annuloplasty dehiscence found to be secondary to nitinol clip detachment,

and another leaflet-related jet can be seen adjacent to the site of dehis-

cence. (D) Three-dimensional TEE en-face view of the mitral valve showed

the native valve annulus remained intact despite the localized area of

annuloplasty dehiscence (arrowheads). (E) Intraoperative photograph

depicting gross site of nitinol clip failure (arrowheads). (F) Intraoperative

photograph of the posterior leaflet showing the site of leaflet suture

dehiscence (arrows). Dehiscence is also a risk for red blood cell damage and

may present as hemolysis (2). Used with permission from the Mayo Clinic.

Abbreviations as in Figure 1.

FIGURE 6 Extreme Dehiscence of Complete Annuloplasty Ring

A 65-year-old man with a history of severe mitral regurgitation status

post–mitral valve repair 1 year ago at an outside institution presented

seeking a second opinion after being told he had recurrent regurgita-

tion. (A) TEE mid-esophageal view revealed extensive dehiscence of his

complete annuloplasty ring into the left atrium, approximately 2 cm

above the plane of the mitral annulus. (B) TEE mid-esophageal view

with color Doppler (baseline shifted) identified 2 regurgitant jets orig-

inating below the ring at the level of the native annulus as a result of

primary leaflet pathology. (C) Three-dimensional TEE image shows how

the detached ring (arrows) did not interfere with leaflet function given

the superior location of the ring relative to the plane of leaflet coap-

tation. (D) Three-dimensional TEE with color flow demonstrated the

origin and trajectory of the 2 jets of mitral regurgitation, with the larger

jet directed at the detached ring (arrows). Used with permission from

the Mayo Clinic. AR ¼ annuloplasty ring; LAA ¼ left atrial appendage;

MV ¼ mitral valve; other abbreviations as in Figure 1.

J A C C : C A R D I O V A S C U L A R I M A G I N G , V O L . 8 , N O . 1 0 , 2 0 1 5 Spoon et al.O C T O B E R 2 0 1 5 : 1 2 2 3 – 7 Mechanisms of Mitral Valve Repair Failure

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ACKNOWLEDGMENTS The authors thank Mark A. Zangs for his time and expertise in image construction, aswell as Dr. William D. Edwards for his expert review.

REPRINT REQUESTS AND CORRESPONDENCE: Dr. Jocelyn N. Spoon, Division of Cardiovascular Diseases,Mayo Clinic, 200 First Street SW, Rochester, Minnesota 55905. E-mail: jocy.huey@gmail.com OR Dr. Vuyisile T.Nkomo, Division of Cardiovascular Diseases, Mayo Clinic, 200 First Street SW, Rochester, Minnesota 55905.E-mail: nkomo.vuyisile@mayo.edu.

R EF E RENCE S

1. Suri RM, Schaff HV, Dearani JA, et al. Recurrentmitral regurgitation after repair: should the mitralvalve be re-repaired? J Thorac Cardiovasc Surg2006;132:1390–7.

2. Yeo TC, Freeman WK, Schaff HV, Orszulak TA.Mechanisms of hemolysis after mitral valve repair:assessment by serial echocardiography. J Am CollCardiol 1998;32:717–23.

KEY WORDS mitral valve prolapse,mitral valve repair, primary mitral valveregurgitation