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Apical Displacement Of Bioprosthetic Mitral Valve Resulting In Left Ventricular Outflow Tract Obstruction
Mohammad Hamidi, Rajesh Janardhanan, Toshinobu Kazui.
The University of Arizona, Tucson, AZ, USA.

OBJECTIVE:
Left ventricular outflow obstruction (LVOTO) after mitral valve replacement (MVR) with preserving anterior mitral valve leaflet in the acute phase has been reported. However, LVOTO after MVR with preserving anterior mitral valve leaflet in chronic phase hasn't been well described.
METHODS:
We are presenting a unique case of redo mitral valve replacement with the indication of LVOTO secondary to apical displacement of the bioprosthetic mitral valve 10 years after the index operation.
RESULTS:
Our patient is a 71-year-old male with a history of MVR (Medtronic Mosaic 29mm with anterior and posterior leaflets and chordal preservation, modified Maze procedure with left atrial appendage ligation) who was admitted to the hospital for severe dyspnea on exertion. Transesophageal echocardiography (TEE) revealed a left ventricular ejection fraction (LVEF) of 60%, severe bioprosthetic mitral valve stenosis (MS) with a mean mitral gradient of 29 mmHg, and apically displaced prosthetic mitral valve causing LVOTO. In addition, severe MS resulted in pulmonary hypertension (PH) (PA = 91/45 mmHg, Mean:60 mmHg, PAW= 32 mmHg, Transpulmonary Gradient: 28 mmHg), which contributed to right ventricular (RV) septal shift toward the left ventricle and caused aggravated LVOTO.Patient underwent redo MVR (STJ Epic 33mm). Immediate postoperative TEE showed no perivalvular leak with an improved mean gradient across the mitral valve (4 mmHg) and LVOT gradient of 6 mmHg, and normal LV / RV function. The patient subsequently recovered and was discharged home on postoperative day 9.
CONCLUSIONS:
Bioprosthetic MVR with anterior leaflet/ chordal preservation can cause apical displacement of the valve causing LVOTO and PH in the long term. Care needs to be taken for patients with narrowed mitral angle, small LV, hyper contractile LV to prevent LVOTO.


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