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Atrioventricular Groove Hematoma During Mitral Valve/Tricuspid Valve Repair

Transesophageal Echocardiography Characteristics

Kumar, Aseem, MD; Fitzsimons, Brian, MD; Trombetta, Carlos, MD

doi: 10.1213/ANE.0b013e318284776f
Cardiovascular Anesthesiology: Echo Didactics & Rounds
Free
SDC

Published ahead of print March 14, 2013

From the Department of Cardiothoracic Anesthesia, Cleveland Clinic, Cleveland, Ohio.

Accepted for publication December 12, 2012.

Published ahead of print March 14, 2013

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 Web site (www.anesthesia-analgesia.org).

Consent from this patient could not be obtained because of loss of communication. IRB guidelines were followed and permission was obtained before submission of this report.

Reprints will not be available from the authors.

Address correspondence to Aseem Kumar, MD, Department of Cardiothoracic Anesthesia, Cleveland Clinic, 9500 Euclid Ave., Cleveland, OH 44195. Address e-mail to aseemk04@gmail.com.

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CASE PRESENTATION

A 77 year-old woman with history significant for hypertension, hypercholesterolemia, and atrial fibrillation presented for mitral valve (MV) and tricuspid valve (TV) repair for severe degenerative valvular disease. After uneventful induction of general anesthesia, the transesophageal echocardiographic (TEE) examination demonstrated a degenerative MV exhibiting severe regurgitation due to flail of the A2 segment from ruptured chordae to the anterior leaflet. Additional findings included moderate TV regurgitation (functional in nature) with preserved biventricular systolic function and no regional wall motion abnormalities (Video 1, see Supplemental Digital Content 1, http://links.lww.com/AA/A515).

Cardiopulmonary bypass (CPB) was initiated using bicaval cannulation and cardioprotection instituted using both antegrade and retrograde cardioplegia. The MV was repaired using Gore-Tex neochords followed by placement of a 35-mm Duran annuloplasty band. Subsequently, the TV was repaired with an annuloplasty ring. After adequate de-airing, as the patient was being weaned off CPB, TEE revealed new-onset severe hypokinesis of the inferior and inferoseptal segments of the left ventricle along with a new echolucent space noted adjacent to the left atrial free wall that was confirmed in multiple views (Figs. 1 and 2; Video 2, see Supplemental Digital Content 2, http://links.lww.com/AA/A516). The patient was immediately returned to full CPB and the echolucent fluid collection was confirmed as an atrioventricular groove hematoma on direct inspection by the surgeon. Next, the MV annuloplasty band was removed with the consideration that one of the sutures might have disrupted the integrity of the atrioventricular groove causing this hematoma. Subsequent to the removal, the MV was confirmed to still be competent by the surgeon. After de-airing and weaning of CPB, TEE revealed persistence of regional wall motion abnormalities in the above-mentioned segments necessitating another return to full CPB. This time a vein graft was used to bypass the posterior descending artery. Subsequent termination from CPB was successful with resolution of inferior and inferoseptal wall motion abnormalities and no increase in size of the atrioventricular groove hematoma. The patient’s postoperative echocardiogram on day 9 showed complete resolution of the hematoma; however, there was return of mitral regurgitation from the anterior leaflet prolapse.

Figure 1

Figure 1

Figure 2

Figure 2

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DISCUSSION

The above-mentioned case had 2 separate complications: atrioventricular groove hematoma and ischemia in the right coronary artery (RCA) distribution. Atrioventricular groove injury is a rare but severe complication after MV procedures that can range from a simple hematoma in the posterior atrioventricular groove to cardiac rupture. The likely cause in our case was from disruption of the integrity of the atrioventricular groove from the mitral annuloplasty ring sutures.

The left atrium being a low-pressure chamber can be easily compressed by external fluid collections such as hematoma and therefore could lead to impairment of pulmonary venous return and thereby failure to wean off CPB.1 Other sources of hematoma in this region include atrial wall, aorta, and coronary sinus (CS) rupture. Although TEE can be very helpful in diagnosing such rare complications, it is not always accurate, and false diagnoses have been reported.2 Hence, a high degree of suspicion is recommended. The atrioventricular groove hematoma in our case was assessed on TEE using multiple views and was found to extend along the posterior left atrial wall in a medial to lateral direction. Viewers should notice the similar echogenicity of the hematoma and the adjacent left atrium and note its close spatial relationship to the underlying CS that runs in the atrioventricular groove. Care should be taken to differentiate this from a CS dissection (from a retrograde cardioplegia catheter) or an enlarged CS. Color flow Doppler assessment can be very useful to ascertain the source and evaluate communication with the surrounding structures.

The presumed cause of the second complication, i.e., ischemia, was attributed to ligation/distortion of the RCA via a suture. Recall that with right dominant distribution, the RCA supplies the inferior and inferoseptal segments of the left ventricle (Fig. 3). Although transient regional wall motion abnormalities due to air are fairly common after a surgical procedure that requires opening of one or more of the cardiac chambers, these abnormalities usually resolve spontaneously over time as air is vented out. New-onset regional wall motion abnormalities in the region of RCA distribution (inferior and inferoseptal segments) along with persistent hemodynamic instability even after resolution of air in the left ventricle was highly suspicious for RCA occlusion in our patient. TEE assessment of the coronary anatomy and flow should include visualization of the left main, left anterior descending, left circumflex coronary artery in midesophageal aortic valve short-axis and midesophageal long-axis views.3 Anomalous origin of coronary arteries is a relatively common finding and therefore correlation recommended with catheterization results when interpreting TEE images.3–5 Color flow Doppler assessment should be applied to assess any stenotic flow in these vessels after repair.5 Anatomically, this patient had right dominance with normal origin of coronary arteries as confirmed from the catheterization report and computed tomography angiogram. The transgastric short-axis and 2-chamber views are used to quantify systolic function by assessment of thickening and excursion of individual segments in relation to the cardiac cycle. The same views can then be used after repair to evaluate for any abnormalities.

Figure 3

Figure 3

The presented case represents the role of intraoperative echocardiography in diagnosing iatrogenic pathology and differentiating it from normal structures in the vicinity. It is imperative that a comprehensive TEE examination be performed before initiating MV repair so that infrequent complications similar to those we presented above can be promptly diagnosed and addressed.

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DISCLOSURES

Name: Aseem Kumar, MD.

Contribution: This author helped design the study and write the manuscript.

Attestation: Aseem Kumar approved the final manuscript.

Name: Brian Fitzsimons, MD.

Contribution: This author helped design the study and write the manuscript.

Attestation: Brian Fitzsimons approved the final manuscript.

Name: Carlos Trombetta, MD.

Contribution: This author helped design the study and write the manuscript.

Attestation: Carlos Trombetta approved the final manuscript.

This manuscript was handled by: Martin J. London, MD.

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REFERENCES

1. Pratap JN, McEwan AI. Failure to wean from cardiopulmonary bypass due to left atrial compression by periaortic hematoma. Anesth Analg. 2009;109:35–7
2. Golorsky E, Golorsky A, Galbul DL, Wolfensen A. Left atrial compression by a pericardial hematoma presenting as an obstructing intracavitary mass: a difficult differential diagnosis. Anesth Analg. 2002;95:567–9
3. Ender J, Singh R, Nakahira J, Subramanian S, Thiele H, Mukherjee C. Echo didactic: visualization of the circumflex artery in the perioperative setting with transesophageal echocardiography. Anesth Analg. 2012;115:22–6
4. Ender J, Gummert J, Fassl J, Krohmer E, Bossert T, Mohr FW. Ligation or distortion of the right circumflex artery during minimal invasive mitral valve repair detected by transesophageal echocardiography. J Am Soc Echocardiogr. 2008;21:408.e4–5
5. Tanzola RC, Allard R. Transesophageal echocardiography of an anomalous circumflex coronary artery: anatomy and implications. Anesth Analg. 2009;109:1029–31
6. Shanewise JS, Cheung AT, Aronson S, Stewart WJ, Weiss RL, Mark JB, Savage RM, Sears-Rogan P, Mathew JP, Quiñones MA, Cahalan MK, Savino JS. ASE/SCA guidelines for performing a comprehensive intraoperative multiplane transesophageal echocardiography examination: recommendations of the American Society of Echocardiography Council for Intraoperative Echocardiography and the Society of Cardiovascular Anesthesiologists Task Force for Certification in Perioperative Transesophageal Echocardiography. Anesth Analg. 1999;89:870–84
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Clinician’s Key Teaching Points

By Kent H. Rehfeldt, MD, and Nikolaos J. Skubas, MD

  • Mitral valve (MV) surgery may be complicated by injury to neighboring structures such as the atrioventricular groove or coronary arteries. Iatrogenic atrioventricular groove injuries are uncommon and range in severity from simple hematoma to cardiac disruption. Awareness of potential sites of surgical injury facilitates their identification by the intraoperative echocardiographer.
  • A hematoma in the atrioventricular groove appears as an echolucent space of variable size, adjacent to the left atrial free wall, running in a medial-lateral direction above the mitral annulus. It should be differentiated from the coronary sinus or hematomas resulting from injury to the left atrium or aorta. The new appearance of an echolucent structure after cardiopulmonary bypass should raise suspicion for iatrogenic injury; color flow Doppler should be used to detect communication with a cardiac chamber, as is the case of a large coronary sinus.
  • In this case after insertion of a mitral ring, a new-onset echolucent space was imaged lateral to the left atrial wall in the midesophageal 2-chamber view, along with new hypokinesis of the inferior and inferoseptal wall segments. This prompted return to cardiopulmonary bypass for removal of the MV ring and placement of a bypass graft to the right coronary artery.
  • New echocardiographic findings after MV surgery should raise the suspicion of iatrogenic injury to neighboring structures. Comparison to a baseline, comprehensive transesophageal echocardiographic examination will enable the differentiation from normal findings, such as a large coronary sinus or preexisting regional wall abnormalities. Because anomalous coronary arteries are encountered regularly, echocardiographic findings should be correlated with preoperative coronary angiography when possible.

Supplemental Digital Content

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© 2013 International Anesthesia Research Society