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Asian Cardiovasc Thorac Ann 2006;14:537
© 2006 Asia Publishing EXchange Ltd

LETTER TO EDITOR

LEFT VENTRICLE RUPTURE AFTER MITRAL VALVE REPLACEMENT

Jaswinder Singh, MCh, Rajeshwar Sharma, MS, Rajinder S Dhaliwal, MCh

Department of Cardiovascular and Thoracic Surgery, Postgraduate Institute of Medical Education & Research, Chandigarh 160 012, India

We read with interest the article by Zhang HJ et al.1 Authors have described a total of 13 cases of left ventricular rupture, of these 11 patients had mechanical valve placed with continuous suture technique, whereas 2 bioprostheses were inserted with interrupted sutures. Could it be possible that continuous suture technique in calcific annulus is a risk factor for left ventricular rupture? We would like to emphasize few points regarding the measure to be taken to prevent LV rupture, as prevention is the best form of treatment for this virtually lethal entity. As mentioned in the article there are several causes for LV rupture during mitral valve replacement, most common of these contributing factors are:2,3

  1. Undue traction on annulus during excision of mitral leaflet or insertion of prosthesis.
  2. Tearing of the annulus by sutures already placed when heart is manually tilted up after mitral valve prosthesis is in place.
  3. Penetration of stitches into the left atrioventricular groove posteriorly.
  4. Perforation of LV wall as papillary muscle is excised.
  5. Perforation of AV groove as calcific deposits is removed.
  6. Perforation by apex vent, which is rare now as apical vent is not being placed.
  7. Strut perforation by high profile valve.
  8. More likely to occur in women and in patients with small LV.

Surgeon must be very gentle in all maneuvers during mitral valve replacement and should avoid doing the following:4

  1. The heart should not be tipped up for air evacuation or ligation of left atrial appendage or for routine inspection of the back of the heart after the prosthesis has been inserted.
  2. Should not excise whole of the papillary muscle rather only chordae tendineae should be excised.
  3. Simply leave in place deeply embedded calcific deposits in the annulus and place suture around them or only on their atrial side.
  4. Perform the chordal sparing MVR.
  5. Should not try to push or place an over sized valve.
  6. Should avoid using high profile valve.
  7. Should avoid forceful manual compression of heart for de-airing or over distension.

REFERENCES

  1. Zhang HJ, Ma WG, Xu JP, Hu SS, Zhu XD. Left Ventricular Rupture after mitral valve replacement: A report of 13 cases. Asian Cardiovasc Thorac Ann 2006;14:26–9.[Abstract/Free Full Text]

  2. Bjork VO, Henze A, Rodriguez L. Left ventricular rupture as a complication of mitral valve replacement: surgical experience with eight cases and a review of literature. J Thorac Cardiovasc Surg 1979;73:14.

  3. Robert WC, Morrow AG. Causes of early post operative death following cardiac valve replacement: clinicopathological correlation in 64 patients studied at necropsy, J Thorac Cardiovasc Surg 1967;54:422.[Medline]

  4. Mitral valve Disease with or without Tricuspid Valve Disease. Nicholas T. Kouchoukos, Eugene H Blackstone, Donald B Doty, Frank h Hanley, Robert B Karp In Kirklin / Barratt-Boyes Cardiac Surgery 3rd Edition Volume I; Churchill Livingstone 2003;483–553.





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