JACC: CASE REPORTS

VOL. 2, NO. 10, 2020

ª 2020 PUBLISHED BY ELSEVIER ON BEHALF OF THE AMERICAN COLLEGE OFCARDIOLOGY FOUNDATION. THIS IS AN OPEN ACCESS ARTICLE UNDER THE
CC BY-NC-ND LICENSE (http://creativecommons.org/licenses/by-nc-nd/4.0/).

MINI-FOCUS ISSUE: IMAGINGIMAGING VIGNETTE: CLINICAL VIGNETTE

An Unusual Case of
Bioprosthetic Mitral Valve Failure
Shiro Miura, MD, MSC,a Takehiro Yamashita, MD, PHD,a Masaki Murata, MD, PHD,b Hiroyuki Iwano, MD, PHD,cYouhei Ohkawa, MD, PHDdABSTRACT
We report a case of sudden-onset pulmonary edema due to failure of a bioprosthetic mitral valve. Gross inspection
revealed a leaﬂet tear at a stent post without calciﬁcation or pannus formation and no evidence of sutures. This casehighlights the mechanical failure of a bioprosthetic mitral valve associated with missing sutures. (Level of Difﬁculty:Intermediate.) (J Am Coll Cardiol Case Rep 2020;2:1572–4) © 2020 Published by Elsevier on behalf of theAmerican College of Cardiology Foundation. This is an open access article under the CC BY-NC-ND license(http://creativecommons.org/licenses/by-nc-nd/4.0/).

An 86-year-old man with a medical history of surgical mitral replacement 10 years prior with a 27-mm
Carpentier-Edwards Perimount plus pericardial mitral valve (Model 6900P, Edwards Lifesciences,
Irvine, California) due to post-inﬂammatory mitral stenosis presented with acute onset of feverand dyspnea. On admission, his blood pressure, pulse rate, body temperature, and oxygen saturation were171/106 mm Hg, 170 beats/min, 37.2 C, and 84% (room), respectively. Physical examination revealed thatbibasilar crackles were heard with no obvious heart murmur or jugular vein distention. Initial transthoracic
echocardiogram (TTE) was notable for a left ventricular ejection fraction of 82% and mild transvalvular
mitral regurgitation (MR) with an effective regurgitant oriﬁce area of 16 mm2 . Subsequent chest computed
tomography examination revealed extensive bilateral inﬁltrates and pleural effusion. Despite elevated whiteblood cell count (14,600/m l) and serum C-reactive protein (7.9 mg/dl), 3 sets of blood cultures were all negative. He was initially diagnosed with community-acquired pneumonia, which responded well to intravenous
ceftriaxone. On hospital day 19, he developed sudden-onset dyspnea; chest radiography revealed bilateralpulmonary congestion (Figure 1A). Vital sign measurements showed a blood pressure of 140/81 mm Hg, heart
rate of 98 beats/min, and oxygen saturation of 88% (room). Chest auscultation was remarkable for bilateralcoarse crackles and a holosystolic murmur (4/6 intensity), maximal at the apex radiating to the axilla. TTE
showed an eccentric, severe MR jet with a prolapsed posteromedial leaﬂet towards the lateral wall of theleft atrium associated with an effective regurgitant oriﬁce area of 41 mm 2 and left ventricular ejection fraction of 79%. Right-sided cardiac catheterization revealed prominent v waves (30 mm Hg) on pulmonary
capillary wedge pressure (PCWP) tracing with a mean PCWP of 24 mm Hg. Serum levels of N-terminal
pro-B-type natriuretic peptide increased from 501 to 10,887 pg/ml. These ﬁndings are consistent with aFrom the aDepartment of Cardiology, Hokkaido Ohno Memorial Hospital, Sapporo, Japan; bDepartment of Surgical Pathology,
Hokkaido Ohno Memorial Hospital, Sapporo, Japan; cDepartment of Cardiovascular Medicine, Faculty of Medicine andGraduate School of Medicine, Hokkaido University, Sapporo, Japan; and the dDepartment of Thoracic and CardiovascularSurgery, Hokkaido Ohno Memorial Hospital, Sapporo, Japan. The authors have reported that they have no relationships
relevant to the contents of this paper to disclose.
The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’
institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information,
visit the JACC: Case Reports author instructions page.
Manuscript received February 6, 2020; revised manuscript received May 15, 2020, accepted May 27, 2020.

ISSN 2666-0849

https://doi.org/10.1016/j.jaccas.2020.05.090

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Bioprosthetic Mitral Valve Failure

diagnosis of acute MR associated with cardiogenic pulmonary edema. Intravenous

ABBREVIATIONS

diuretics were initiated immediately, resulting in insufﬁcient hemodynamic

AND ACRONYMS

improvement. A transesophageal echocardiogram performed on hospital day 23
revealed a torn mitral valve leaﬂet undergoing prolapse into the left atrium(Figures 1B to 1D, Videos 1 and 2). Although percutaneous valve-in-valve implantation was considered a promising option (1), this procedure is not fully reimbursed
for clinical use in Japan. On hospital day 23, after multidisciplinary discussion be-MR = mitral regurgitation
PCWP = pulmonary capillarywedge pressure

TTE = transthoracic
echocardiogram

tween the cardiology and cardiothoracic surgery departments, the failed valve wassurgically replaced with a 29-mm St. Jude Medical mechanical valve (St. Jude Medical, Inc., St. Paul, Minnesota), which was selected based on several factors: valve durability, re-intervention risks, the need for

F I G U R E 1 Imaging and Pathologic Findings(A) Chest radiograph from hospital day 19 revealed bilateral pulmonary congestion. (B) Transesophageal echocardiogram (TEE) (left) withcolor Doppler (right) documented a leaﬂet tear prolapsing into the left atrium during systole in association with signiﬁcant mitral regurgitation (MR) (Video 1). (C) Three-dimensional (3D) TEE image, viewed from the left atrium conﬁrmed prolapse (red arrow) in the posteromedial leaﬂet where (D) an eccentric transvalvular MR jet (red arrowhead) was directed at the lateral wall of the left atrium; and 3D color
Doppler image (Video 2). (E) Flow and (F) non-ﬂow surfaced of the excised bioprosthetic mitral value revealed a slit-like tear (redarrowhead) along the stent post on the affected side; no signiﬁcant leaﬂet calciﬁcation, pannus formation, or valve thrombosis wasobserved. (G) Histologic ﬁndings (hematoxylin and eosin staining) highlight the area within the square, as shown in E. Sutures were partiallyabsent along the stent post on the affected side (red arrowhead); sutures supporting the stent post were present on the opposite side(asterisk).

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long-term anticoagulation, and patient preference as per international guidelines (2). The patient was uneventfully discharged on postoperative day 33.
Pathologic examination revealed a slit-like leaﬂet tear along one side of the stent post with no signiﬁcantcalciﬁcation, pannus formation, or valve thrombosis (Figures 1E and 1F). Histologically, no sutures weredetected at the affected side of the stent post, although they were clearly present along the opposite side of thevalve (Figure 1G). Microscopic examination revealed no signiﬁcant inﬂammation, ﬁbrosis, calciﬁcation, or
myxomatous degeneration that may contribute to a leaﬂet tear of this nature (3). Accordingly, we concludedthat the missing sutures most likely played a pivotal role in promoting acute prosthetic valve dysfunction,although we do not know whether the sutures were absent initially or became unfastened over the years ofuse. There is reportedly an intense concentration of tensile stress at the top of the stent post (i.e., thecommissure), roughly 5 times greater than the maximum detected at the center of the leaﬂet (4). Moreover, thehemodynamic changes and systemic inﬂammation related to community-acquired pneumonia may have had
an indirect negative impact on valve function.
ADDRESS FOR CORRESPONDENCE: Dr. Shiro Miura, Department of Cardiology, Hokkaido Ohno Memorial

Hospital, 2-1-16-1 Miyanosawa, Nishi-ku, Sapporo 063-0052, Japan. E-mail: s.miura@ohno-kinen.or.jp.

REFERENCES
1. Wilbring M, Alexiou K, Tugtekin SM, et al.
Transapical transcatheter valve-in-valve implantation for deteriorated mitral valve bioprostheses.
Ann Thorac Surg 2013;95:111–7.
2. Nishimura RA, Otto CM, Bonow RO, et al. 2014
AHA/ACC guideline for the management of patients with valvular heart disease: a report of theAmerican College of Cardiology/American Heart

Association Task Force on Practice Guidelines.
Circulation 2014;129:e521–643.

calciﬁc degeneration. J Heart Valve Dis 1996;5:35–9.

3. Siddiqui RF, Abraham JR, Butany J. Bioprosthetic heart valves: modes of failure. Histopathology 2009;55:135–44.

KEY WORDS echocardiography, imaging,
mitral valve, valve replacement

4. Haziza F, Papouin G, Barratt-Boyes B, et al.

AP PE NDIX For supplemental videos,Tears in bioprosthetic heart valve leaﬂets without

please see the online version of this paper.