Complicated third sternotomy for left ventricular outflow tract obstruction secondary to mitral valve prosthesis strut

Abstract

Introduction: LVOT obstruction after surgical bioprosthetic MVP placement is uncommon and the influence of the MVP strut width has seldom been examined.

Case presentation: A 74-year-old female presented with palpitations, chest pain, and shortness of breath. She had MVR with 31-mm bioprosthetic valve 2 years prior. TEE confirmed LVOT secondary to a MVP strut, causing a peak gradient of 55 mmHg. The redo operation was complicated by iatrogenic Type-A aortic dissection. The patient was immediately cooled for DHCA with RCP and ascending aortic replacement was performed. MVR was then performed with a prosthesis with narrower strut width. Recovery after surgery was uneventful and post-TEE confirmed absence of LVOT obstruction (gradient of 4 mmHg).

Discussion: This case is of interest for two reasons. Primarily, the overall profile of the valve, including the width of the struts may play a significant role in the development of LVOT obstruction after MVR. Additionally, the patient had an ITAAD requiring prompt and thoughtful management.

Conclusion: This case underscores the importance of evaluating MVP profile in relation to patient anatomy. Furthermore, intraoperative Type A aortic dissection is a rare but lethal phenomenon requiring swift decision-making and technical ability, and both are important considerations for trainees.