Complicated third sternotomy for left ventricular outflow tract obstruction secondary to mitral valve prosthesis strut.

Introduction

LVOT obstruction after surgical bioprosthetic MVP placement is uncommon and the influence of the MVP strut width has seldom been examined. Case presentation: A 74-year-old female presented with palpitations, chest pain, and shortness of breath. She had MVR with 31-mm bioprosthetic valve 2 years prior. TEE confirmed LVOT obstruction secondary to a MVP strut, causing a peak gradient of 55 mmHg. The redo operation was complicated by iatrogenic Type A aortic dissection. The patient was immediately cooled for DHCA with RCP and ascending aortic replacement was performed. MVR was then performed with a prosthesis with narrower strut width. Recovery after surgery was uneventful and post-bypass TEE confirmed absence of LVOT obstruction (gradient of 4 mmHg). Discussion: This case is of interest for two reasons. Primarily, the overall profile of the valve, including the width of the struts may play a significant role in the development of LVOT obstruction after MVR. Additionally, the patient had an ITAAD requiring prompt and thoughtful management.

Conclusions

This case underscores the importance of evaluating MVP profile in relation to patient anatomy. Furthermore, intraoperative Type A aortic dissection is a rare but lethal phenomenon requiring swift decision-making and technical ability, and both are important considerations for trainees.