Transesophageal echocardiographic imaging of multiple complications following mitral valve replacement

We present a case of mitral valve (MV) replacement that resulted in multiple complications, as diagnosed by transesophageal echocardiography (TEE), including left ventricular outflow tract obstruction, aortic dissection and left ventricular rupture. We also describe that identification of bleeding originating from the posterior aspect of the heart by the surgical team should trigger a complete TEE evaluation for adequate diagnosis. An 84-year-old woman underwent a MV replacement. Weaning from cardiopulmonary bypass (CPB) revealed a late-peaking gradient of 44 mmHg over the left ventricular outflow tract caused by obstruction from a bioprosthetic strut. After proper surgical correction, TEE evaluation showed a type A aortic dissection that was subsequently repaired. After separation from CPB, the surgical team identified a major bleed that originated from the posterior aspect of the heart. Although the initial suspicion was injury to the atrioventricular groove, a complete TEE evaluation confirmed a left ventricular free wall rupture by showing the dissecting jet using colour-flow Doppler. TEE is an essential component in cardiac surgery for assessment of surgical repair and potential complications. Posterior bleeding should trigger a complete TEE examination with assessment of nearby structures to rule out a life-threatening pathology. Left ventricular free wall rupture can be identified using colour-flow Doppler. LEARNING POINTS: Multiple complications may occur after MVR. TEE is an essential component in the evaluation of surgical repair and its potential associated complications, including LVOT obstruction, aortic dissection and LV rupture. Posterior bleeding, from the region of AV groove, should trigger a complete TEE examination with assessment of nearby structures such as the atria, coronary sinus and myocardium to rule out a life threatening pathology. The diagnosis of a LV rupture can be confirmed with 2-D imaging and colour-flow Doppler demonstrating a dissecting jet through the myocardium.