From the Department of Cardiothoracic Anesthesia, Cleveland Clinic, Cleveland, Ohio.
Checking for direct PDF access through Ovid
CASE PRESENTATIONA 77 year-old woman with history significant for hypertension, hypercholesterolemia, and atrial fibrillation presented for mitral valve (MV) and tricuspid valve (TV) repair for severe degenerative valvular disease. After uneventful induction of general anesthesia, the transesophageal echocardiographic (TEE) examination demonstrated a degenerative MV exhibiting severe regurgitation due to flail of the A2 segment from ruptured chordae to the anterior leaflet. Additional findings included moderate TV regurgitation (functional in nature) with preserved biventricular systolic function and no regional wall motion abnormalities (Video 1, see Supplemental Digital Content 1, http://links.lww.com/AA/A515).Cardiopulmonary bypass (CPB) was initiated using bicaval cannulation and cardioprotection instituted using both antegrade and retrograde cardioplegia. The MV was repaired using Gore-Tex neochords followed by placement of a 35-mm Duran annuloplasty band. Subsequently, the TV was repaired with an annuloplasty ring. After adequate de-airing, as the patient was being weaned off CPB, TEE revealed new-onset severe hypokinesis of the inferior and inferoseptal segments of the left ventricle along with a new echolucent space noted adjacent to the left atrial free wall that was confirmed in multiple views (Figs. 1 and 2; Video 2, see Supplemental Digital Content 2, http://links.lww.com/AA/A516). The patient was immediately returned to full CPB and the echolucent fluid collection was confirmed as an atrioventricular groove hematoma on direct inspection by the surgeon. Next, the MV annuloplasty band was removed with the consideration that one of the sutures might have disrupted the integrity of the atrioventricular groove causing this hematoma. Subsequent to the removal, the MV was confirmed to still be competent by the surgeon. After de-airing and weaning of CPB, TEE revealed persistence of regional wall motion abnormalities in the above-mentioned segments necessitating another return to full CPB. This time a vein graft was used to bypass the posterior descending artery. Subsequent termination from CPB was successful with resolution of inferior and inferoseptal wall motion abnormalities and no increase in size of the atrioventricular groove hematoma. The patient’s postoperative echocardiogram on day 9 showed complete resolution of the hematoma; however, there was return of mitral regurgitation from the anterior leaflet prolapse.DISCUSSIONThe above-mentioned case had 2 separate complications: atrioventricular groove hematoma and ischemia in the right coronary artery (RCA) distribution. Atrioventricular groove injury is a rare but severe complication after MV procedures that can range from a simple hematoma in the posterior atrioventricular groove to cardiac rupture. The likely cause in our case was from disruption of the integrity of the atrioventricular groove from the mitral annuloplasty ring sutures.The left atrium being a low-pressure chamber can be easily compressed by external fluid collections such as hematoma and therefore could lead to impairment of pulmonary venous return and thereby failure to wean off CPB.1 Other sources of hematoma in this region include atrial wall, aorta, and coronary sinus (CS) rupture. Although TEE can be very helpful in diagnosing such rare complications, it is not always accurate, and false diagnoses have been reported.2 Hence, a high degree of suspicion is recommended. The atrioventricular groove hematoma in our case was assessed on TEE using multiple views and was found to extend along the posterior left atrial wall in a medial to lateral direction. Viewers should notice the similar echogenicity of the hematoma and the adjacent left atrium and note its close spatial relationship to the underlying CS that runs in the atrioventricular groove.