2025 Volume 7 Issue 10 Pages 995-996
An 86-year-old man with a Clinical Frailty Scale score of 2 presented with exertional dyspnea. He had undergone surgical aortic valve replacement (SAVR) at 70 years of age. During follow up, mitral regurgitation was documented, but was managed conservatively because of the absence of symptoms. He developed new-onset atrial fibrillation, and his B-type natriuretic peptide level was elevated (555 pg/mL). Transthoracic echocardiography showed normal left ventricular contraction with concentric hypertrophy, left atrial enlargement, mild prosthetic valve stenosis, and moderate prosthetic valve regurgitation (predominantly paravalvular leakage). Additionally, a flap-like structure suggestive of prolapse at the anterior commissure and an eccentric jet originating near the flap were observed (Figure A–C). We performed transesophageal echocardiography to further evaluate the mitral valve; however, it unexpectedly revealed a fistulous connection between the left ventricular outflow tract (LVOT) and the left atrium, with abnormal systolic flow through a perforation with a visible flap (Figure D–G; Supplementary Movies 1,2). Given the worsening heart failure symptoms, redo-SAVR and patch closure of the fistula were planned due to the paravalvular leakage and his preserved operability. Intraoperative findings revealed a 3-mm defect connecting the LVOT to the left atrium, located immediately below the left coronary cusp, as seen from the ascending aorta after removal of the prosthetic valve (Figure H). The defect was suspected to be of iatrogenic origin related to the initial SAVR. It was closed with a pericardial patch (Figure I), and a new prosthetic valve was implanted. The postoperative course was uneventful.
(A–C) Transthoracic echocardiography showed a flap-like structure and an eccentric jet originating near the flap. (D–G) Transesophageal echocardiography showed abnormal systolic flow through a perforation with a visible flap like a part of the aortomitral continuity. (H,I) Intraoperative images viewed from the ascending aorta. LA, left atrium; LV, left ventricle; LVOT, left ventricular outflow tract; MV, mitral valve.
We thank Angela Morben, DVM, ELS, from Edanz (https://jp.edanz.com/ac), for editing a draft of this manuscript.
None.
Supplementary Movie 1. Three-dimensional en face view of the mitral valve obtained by transesophageal echocardiography.
Supplementary Movie 2. Abnormal systolic flow through a perforation visualized by three-dimensional transesophageal echocardiography.
Please find supplementary file(s);
https://doi.org/10.1253/circrep.CR-25-0118
