The Road to Nowhere

You are probably familiar with the following situation: you have a patient who is in desperate need of some kind of treatment, but none of the options are very appealing. One of those cases which you simply feel like “giving up”. Here is such a case. Several things went wrong and put the patient into a very dismal situation.

Martha worked in the kitchen of a large canteen. She was obese and by no means physically active. At the age of 55 years she was told that she had a mitral valve prolapse and mitral regurgitation, but need not worry. She went for regular check ups at which she was told that everything was fine. Two years after mitral valve prolapse had been diagnosed, Martha started to feel a little short of breath. She went to her cardiologist, who couldn't locate the cause. Another year went by. The cardiologist finally sent her to a cardiothoracic center for possible mitral valve surgery. Mitral regurgitation was severe at the time, and left ventricular function had already deteriorated.
Those of you who read our blog posts and are also members of our Masterclass know that mitral valve surgery should not be delayed when symptoms appear. It is imperative to perform surgery before the left ventricle fails. Mitral valve reconstruction and annuloplasty (plus tricuspid valve annuloplasty) was performed shortly thereafter.

Was she off the hook?

Martha woke up, relieved that everything was over. But was everything really fine? We saw her three months later with more dyspnea than ever. She could hardly do her housework. She sat upright on her bed all night with orthopnea. Take a look at the echo we recorded. Can you see what the problem is just by looking at the 2D image?

Parasternal long-axis view. Take a close look at the annuloplasty ring.

The two dots below the mitral valve mark the annuloplasty ring. Isn't there something strange there? Let us look at the problem in greater detail:

Zoom view of the annuloplasty ring.

The ring looks fairly small to me, but this by itself is not the problem. Quite often, especially when left ventricular function is poor, the surgeon undersizes the ring to prevent further annular dilatation.
However, there is no connection between the posterior part of the ring and the supraannular tissue of the mitral valve. The ring is dehiscent. What effect does this have on mitral valve function?

Not again!

It is no surprise to note that the mitral valve is incompetent. The ring does not do what it is supposed to do.

Severe mitral regurgitation.

The jet passes between the posterior leaflet and the annuloplasty ring. One might refer to this condition as periannular mitral regurgitation.

Another major problem

Unfortunately this is not Martha's only problem. You might have suspected her additional problem from the images I showed you: her left ventricular function is poor. This can be appreciated on the short-axis view of the left ventricle.

Short-axis view. The left ventricle is severely dilated and global left ventricular function is poor.

Remember: her preoperative left ventricular function was already poor, but now it is catastrophic. Here is another view that shows you the full extent of the problem.

Four-chamber view – color Doppler.

She is already under treatment for heart failure and is receiving increasing doses of diuretics. What further options do we have?

It is your turn now

Would you operate again? Remember the left ventricle could easily fail if afterload increases when regurgitation is abolished. Are there any other options or is this really “the road to nowhere”? I would be curious to know what you think. I know the outcome, but you'll have to wait until next week to find out what happened to Martha.

PS: If you know colleagues or friends who might benefit from the information presented in this post, please forward it to them.
PPS: If you want to read other blog posts that address the subject of mitral regurgitation, click here or here.