Yonsei Medical Journal Vol. 47, No. 3, pp. 440 - 442, 2006 Tearing of the Mitral Valve during Vent Removal after a Successful Mitral Valve Repair: a Beneficial Role of Transesophageal Echocardiography Ji Young Kim,1 Young Jun Oh,2 Yong Kyung Lee,3 and Young Lan Kwak2,4 1Department of Anesthesiology and Pain Medicine, Gachon University of Medicine and Science Gil Medical Center, Incheon, Korea; 2Department of Anesthesiology and Pain Medicine and Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea; 3Department of Anesthesiology and Pain Medicine, Kwandong College of Medicine, Myongji Hospital, Goyang, Korea; 4Yonsei Cardiovascular Research Institute, Seoul, Korea. In this case, a successful mitral valve repair was confirmed by transesophageal echocardiography (TEE) at the end of a cardiopulmonary bypass. The left ventricular vent was placed through the mitral valve to remove the air after the TEE ex- amination, and on its way out, the left ventricular vent damaged the anterior mitral leaflet (AML). Re-examination of the valve with TEE detected the new mitral valve insuffici- ency. The CPB was reinstituted, and tearing of the lateral third part of the anterior mitral leaflet was found. This case emphasizes the importance of TEE in the operating room as a continuous monitor, not only to evaluate the result of the cardiac surgery, but also to detect any unpredictable events during the surgery. Key Words: Transesophageal echocardiography, mitral valve insufficiency INTRODUCTION Intraoperative decisions are often based on the interpretation of results from intraoperative tran- sesophageal echocardiography (TEE). Residual mitral valve insufficiency at the completion of a Received February 18, 2005 Accepted April 19, 2005 Reprint address: requests to Dr. Young Lan Kwak, Department of Anesthesiology and Pain Medicine and Anesthesia and Pain Research Institute, Yonsei Cardiovascular Research Institute, Yonsei University College of Medicine, 134 Shinchon-dong, Seodaemun-gu, Seoul 120-752, Korea. Tel: 82-2-2228-8500, Fax: 82-2-364-2951, E-mail: ylkwak@yumc.yonsei.ac.kr Yonsei Med J Vol. 47, No. 3, 2006 valve repair is a well-known risk factor for late reoperation, and the use of TEE has decreased the incidence of immediate repair failure.1,2 However, the development of a new mitral valve insuf- ficiency after the removal of the left ventricular vent is rare. This case emphasizes the importance of TEE as a continuous monitor during cardiac surgery. Usually, TEE is used to assess the valve function at the end of the surgery in the operating room, but an unexpected event can occur at any time after the inspection, as in this case, in which the mitral valve was damaged during the left ventricular vent removal. CASE REPORT A 53-year-old female patient with mitral valve insufficiency underwent surgery for mitral valve repair. She had no history of medical illness until the day she was diagnosed with mitral valve insufficiency after an incidence of the syncope seven months previously. The dyspnea upon exertion grew worse, and by the time of the operation her symptoms of congestive heart fail- ure were classified as New York Heart Associa- tion functional class III. Her transthoracic echocar- diography (TTE) revealed a flail posterior mitral leaflet (PML) with an eccentric mitral valve insufficiency of grade IV/IV. The left ventricular ejection fraction was 89%. A preoperative TEE