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Iatrogenic Mitral Regurgitation After Muscular Ventricular Septal Defect Repair Detected by Transesophageal Echocardiography in a Pediatric Patient

Jang, Young-Eun MD*; Kwak, Jae Gun MD, PhD; Min, Joon-Cheol MD; Kim, Eun-Hee MD*; Kim, Jin-Tae MD, PhD*; Kim, Hee-Soo MD, PhD*; Lee, Ji-Hyun MD*

doi: 10.1213/XAA.0000000000000936
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From the *Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea

Department of Thoracic and Cardiovascular Surgery, Seoul National University Children’s Hospital, Seoul, Republic of Korea.

Accepted for publication October 8, 2018.

Funding: None.

The authors declare no conflicts of interest.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website.

Address correspondence to Ji-Hyun Lee, MD, Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehakno, Jongnogu, Seoul 03080, Republic of Korea. Address e-mail to muslab@hanmail.net.

A16-month-old boy (10.0 kg) was admitted for surgical correction of a secundum atrial septal defect and a muscular ventricular septal defect. After inducing anesthesia, transesophageal echocardiography (TEE; iE33 xMATRIX, s7-3t pediatric transducer; Philips Healthcare, Andover, MA) revealed a large secundum atrial septal defect and a small anterior muscular ventricular septal defect (Figure 1).

Figure 1.

Figure 1.

The ventricular septal defect was closed by the sandwich technique using 2 polytetrafluoroethylene patches, one on each side of the ventricular septum. The left ventricle–sided ventricular septal defect patch was passed through the atrial septal defect and mitral valve and pulled toward the ventricular septum, and the right ventricle–sided patch was applied through the transatrial approach. The atrial septal defect was repaired with an autologous pericardial patch. Immediately after weaning from cardiopulmonary bypass (CPB), color Doppler images showed no residual intracardiac shunt. However, color Doppler at the midesophageal 4-chamber and 2-chamber views showed severe eccentric mitral regurgitation with a jet directed toward the interatrial septum (Supplemental Digital Content, Video 1, http://links.lww.com/AACR/A233) and flow acceleration in the left ventricular outflow tract (Figure 2). Two-dimensional TEE images at the midesophageal 4-chamber, midesophageal 2-chamber, and transgastric basal short-axis views showed restrictive systolic and diastolic motion of the anterior mitral leaflet due to tethering of the mid-anterior mitral leaflet by the left-sided ventricular septal defect patch (Supplemental Digital Content, Video 2, http://links.lww.com/AACR/A234). Suspecting iatrogenic mitral regurgitation after ventricular septal defect repair, we recommended reexploration to the surgeon.

Figure 2.

Figure 2.

On surgical inspection of the mitral valve during a second CPB run, chordae from the anterolateral papillary muscle attached to the A2 segment of the anterior mitral leaflet were seen to be trapped by a suture from the ventricular septal defect patch. Thus, the initially applied ventricular septal defect patch and sutures were removed and cautiously reestablished avoiding a pull on the chordae or the anterolateral papillary muscle. Finally, the surgeon confirmed that the subvalvular apparatus was intact.

The child was successfully weaned off CPB, and the postbypass TEE showed good mitral valve leaflet motion without significant mitral regurgitation and a closed muscular ventricular septal defect (Supplemental Digital Content, Video 3, http://links.lww.com/AACR/A235). The postoperative course was uneventful. Informed consent for the publication of this case was obtained.

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DISCUSSION

We reported here a case of severe iatrogenic mitral regurgitation due to chordae entrapment during the closure of an anterior muscular ventricular septal defect. Iatrogenic severe mitral regurgitation after muscular ventricular septal defect repair is a rare complication. Only 1 case of ruptured mitral valve chordae due to trapping of the anterolateral papillary muscle by a muscular ventricular septal defect patch suture has been reported after tetralogy of Fallot repair in an infant.1 It is generally believed that mild mitral regurgitation with a normal mitral valve apparatus improves after intracardiac shunt repair because of the resolution of left heart dilation.2 Thus, newly developed mitral regurgitation after ventricular septal defect repair in a child requires careful evaluation of the underlying cause, especially when no congenital valvular disease exists.

Other serious complications associated with the surgical approach and repair of ventricular septal defect are heart block and injury to the adjacent tricuspid valve, aortic valve, or pulmonary valve.3,4 The transatrial or transpulmonary approach is widely used in cases of conoventricular or conal septal ventricular septal defects.5 Muscular ventricular septal defects, including apical ventricular septal defect, can be transatrially closed through the tricuspid valve.3 Sometimes, the transatrial approach with temporary tricuspid valve detachment can be used for better surgical exposure. However, severe tricuspid regurgitation caused by the dehiscence of the detached site can occur.4

Referenced by right ventricular structures, muscular ventricular septal defect can be categorized according to location as follows: posterior, midventricular, apical, and anterior.5,6 The exact localization of muscular ventricular septal defects with TEE during surgical closure requires multiple 2-dimensional views.7,8Figure 3 shows the location of the muscular ventricular septal defects, and the Table summarizes the TEE views for determining the location of the muscular ventricular septal defects. A muscular ventricular septal defect located between the anterior and apical septum can be visualized in the midesophageal 4-chamber view with anteflexion of the probe and in the midesophageal 2-chamber view with a slight rightward turn of the probe.

Table.

Table.

Figure 3.

Figure 3.

Along with the severe mitral regurgitation on the first postbypass TEE, a turbulent jet flow at the left ventricular outflow tract was found and left ventricular outflow tract obstruction was suspected. Systolic anterior motion of the mitral valve can be suspected in such cases. However, in the present case, the anterior leaflet of the mitral valve was stuck to an object with a high echogenic signal, which was the ventricular septal defect patch, and was deviated toward the interventricular septum.

Other causes of mitral regurgitation include the left ventricle–venting cannula or myocardial ischemia. However, the left ventricle–venting cannula had been removed and there were neither regional wall motion abnormalities nor electrocardiographic changes. After discounting the previously mentioned possibilities, anesthesiologists should perform comprehensive multiplane TEE considering the possibility of iatrogenic mitral valve dysfunction.

In conclusion, we described a case of iatrogenic mitral regurgitation after muscular ventricular septal defect repair. TEE played a critical role in its early recognition and management. When the muscular ventricular septal defect is located near the mitral valve apparatus, the risk of mitral regurgitation after repair should be considered.

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DISCLOSURES

Name: Young-Eun Jang, MD.

Contribution: This author helped prepare the data and draft the manuscript.

Name: Jae Gun Kwak, MD, PhD.

Contribution: This author helped confirm the accuracy and integrity of the manuscript.

Name: Joon-Cheol Min, MD.

Contribution: This author helped confirm the accuracy and integrity of the manuscript.

Name: Eun-Hee Kim, MD.

Contribution: This author helped confirm the accuracy and integrity of the manuscript.

Name: Jin-Tae Kim, MD, PhD.

Contribution: This author helped review the manuscript.

Name: Hee-Soo Kim, MD, PhD.

Contribution: This author helped review the manuscript.

Name: Ji-Hyun Lee, MD.

Contribution: This author helped prepare the data and draft the manuscript.

This manuscript was handled by: Nikolaos J. Skubas, MD, DSc, FACC, FASE.

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REFERENCES

1. Malankar D, Nair VV, Gupta SK, Das S, Airan B. Severe mitral regurgitation after intracardiac repair of tetralogy of Fallot: a rare complication and management. Interact Cardiovasc Thorac Surg. 2014;18:842–843.
2. Cho HJ, Ma JS, Cho YK, Ahn BH, Na KJ, Jeong IS. Timing in resolution of left heart dilation according to the degree of mitral regurgitation in children with ventricular septal defect after surgical closure. J Pediatr (Rio J). 2014;90:71–77.
3. Scully BB, Morales DL, Zafar F, McKenzie ED, Fraser CD Jr, Heinle JS. Current expectations for surgical repair of isolated ventricular septal defects. Ann Thorac Surg. 2010;89:544–549.
4. Mahgoub A, Kamel H, Simry W, Hosny H. Repair of very severe tricuspid regurgitation following detachment of the tricuspid valve. Glob Cardiol Sci Pract. 2015;2015:14.
5. Jacobs JP, Burke RP, Quintessenza JA, Mavroudis C. Congenital heart surgery nomenclature and data base project: ventricular septal defect. Ann Thorac Surg. 2000;69:S25–S35.
6. Jacobs ML, Jacobs JP. Operative techniques for repair of muscularventricularseptaldefects. Oper Tech Thorac Cardiovasc Surg. 2010;15:2–17.
7. Acar P, Abdel-Massih T, Douste-Blazy MY, Dulac Y, Bonhoeffer P, Sidi D. Assessment of muscular ventricular septal defect closure by transcatheter or surgical approach: a three-dimensional echocardiographic study. Eur J Echocardiogr. 2002;3:185–191.
8. Kurokawa S, Taneoka M, Imai H, Baba H, Nomura M. Transesophageal echocardiography detection of undiagnosed multiple muscular ventricular septal defects with alteration of shunt flow by right ventricular pacing after an arterial switch operation in a neonate. Anesth Analg. 2011;113:233–235.

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