Left atrial dissection : An unique complication of mitral valve surgery

doi:10.21203/rs.3.rs-3215147/v1

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Case Report

Left atrial dissection : An unique complication of mitral valve surgery

https://doi.org/10.21203/rs.3.rs-3215147/v1

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Background: Left atrial dissection is an unique but an extremely rare complication associated with cardiac surgery especially mitral valve surgery.

Case Presentation: Here we presented a case report of a 76-year old lady who had mitral valve surgery complicated with left atrial dissection managed surgically. Interestingly, we proposed a new classification of left atrial dissection which could guide the surgeon in the management of this complication.

Conclusions: left atrial dissection might be a lethal complication associated with mitral surgery and can be managed surgically and non surgically depending on the clinical courser and haemodynamic state. The new proposal can help the surgeons to put the management plan.

left atrial dissection

Mitral

iatrogenic

Left atrial dissection is an extremely rare complication of cardiac surgery most commonly associated with mitral surgery. It has been defined as a false tract from mitral annulus to the left atrial free wall or interatrial septum(1) and can be associated with surgical and non-surgical cardiac etiologies (1). Despite being an rare entity (incidence 0.16–0.84%)(1, 3, 6), it may cause serious complications and mortality if it results in hemodynamic instability(1). We present an unusual case of a 72-year old woman who had a unique type of left atrial dissection during mitral surgery.

A 76-year old lady was referred with dyspnoea on exertion. She was known to have severe mitral regurgitation due to A2/ A3 leaflet prolapse of the mitral valve with a very short posterior mitral valve leaflet with a gap and leaflet deficit in the tissues between P2 and P3. She also had moderate tricuspid valve regurgitation and a patent foramen ovale on transesophageal echo (TEE) (Fig. 1.A). Coronary angiogram revealed no flow limiting coronary artery disease and she was known to be in permanent atrial fibrillation.

Median sternotomy was undertaken and total cardiopulmonary bypass(CPB) established. Following aortic cross clamping, the action of the heart was arrested by the instillation of antegrade cold blood cardioplegia.

The mitral valve was approached through the inter-atrial groove. The patent foramen ovale was identified and closed from within the left atrium with continuous prolene.

The mitral valve was inspected and repaired using artificial Gortex chords to A2 and A3 and a 30 mm Edwards Physio 2 ring. Unfortunately, a satisfactory repair could not be constructed due to a very low posterior leaflet which was deficient in leaflet tissue. The anterior leaflet was resected and a mitral valve replacement was performed using size 27 mm Edwards Magna Ease Perimount pericardial valve, which was implanted using interrupted pledgeted sutures. The whole of the posterior leaflet with sub-valvular apparatus was preserved.

The left atrial appendage was occluded with a 35 mm atrial clip, and a tricuspid repair was undertaken by the implantation of a 28 mm Edwards tricuspid Physio ring.

The patient was weaned off cardiopulmonary bypass on the first occasion using moderate doses of inotropic support. In the post bypass period a TEE was undertaken. TEE found a competent tricuspid valve and a competent bioprosthetic mitral valve. However, there was unusual cyst like structure in the free wall of the left atrium with the appearance of a hematoma/dissection, which was obstructing the inflow of the left atrium to the mitral valve. There was no obvious communication with this cyst like structure and the left atrial true lumen(Fig. 1. A).

CPB was re-instigated and the hematoma (dissection) in the posterior wall of the left atrium was identified without any clear source. Additionally, there was an area of hematoma near the base of the atrial appendage. The atrial clip was removed to expose a potential source; none was found and the area was closed with two interrupted prolene pledgeted sutures. The left atrial appendage was then occluded from within the left atrium using continuous prolene and finally the left atrial haematoma was opened to see if there was any source of obvious inflow but none could be found. The left atrial posterior wall was then plicated with continuous prolene suture to occlude any inflow into the inter-atrial wall. The patient was again weaned off CPB on the first occasion using dopamine, noradrenaline and DVI pacing. Post bypass TEE confirmed that the tricuspid and mitral valves were both competent and the left atrial wall had been successfully plicated without evidence of significant residual hematoma within the wall (Fig. 1.B). The inflow to the mitral valve was now normal.

The patient had uneventful post-operative course and has been discharged in postoperative day 12.

Left atrial dissection is defined as a forced separation within the atrial wall layers(4, 5).

This is a rare entity, so the accurate incidence, precipitating factors and management are poorly defined and can only collected from published reports in the literature(1). TEE has a key role in diagnosis and surgical management(3, 4).

The proposed etiologies are surgical (mitral and non-mitral cardiac surgery) and non- surgical which include myocardial infarction, cardiac trauma, percutaneous coronary intervention, radiofrequency ablation, infective endocarditis and amyloidosis (1, 3). As regards mitral surgery, the contributory factors may be aggressive debridement of the valvular and sub-valvular apparatus, prosthesis oversizing, intense traction or inappropriate suturing at the annulus. The pressurized inflow from left ventricle into the entry point is likely the most important factor in the pathogenesis of left atrial dissection(1). Left atrial dissection is most frequently recognized in the posterior or free wall (80.8%) due to muscular attachment of the posterior annulus with little fibrous tissue in the contrast to the anterior annulus(1). This complication may be sub-classiffied as type 1 left ventricle rupture, hence we propose the classification as shown in Figs. 3 &4. Clinically, it varies from a self-limited complication to one which may have a devastating outcome due to hemodynamic instability(1). This instability is usually caused by significant paravalvular leak or obstruction of mitral valve inflow or pulmonary vein orifice leading to low output syndrome which mandates surgical intervention(1, 3).The presentation time varies between immediately intraoperatively to several years later(1, 5). No established guidelines are currently published for the management of this rare entity(1, 3, 4). However, the management varies between conservative for stable cases (26.6%) and surgical (73.4%) especially in unstable patients(1, 3, 4). The surgical principle is the elimination of the false lumen hematoma and closure of any identifiable entry and re-entry points or plication/marsupialization if none can be defined (3). The reported overall mortality rate and for surgical intervention is 12–14%, which compares favourably to LV rupture mortality of 75%(1, 2). In this case, it was an unique complication after mitral surgery with partial rupture of left AV groove resulted in left atrial dissection and bleeding with a resultant intra-atrial hematoma. This complication my be identified as a sub-classification of type 1 left ventricular rupture. We propose a new classification (Figs. 2 &3), in which the first three types are partial rupture and the fourth is a complete rupture. This may help to guide surgical or non-surgical management of this rare complication.

As could be a lethal complication, left atrial dissection is an unique and rare complication associated with mitral surgery and can be managed surgically and non surgically depending on the clinical courser and haemodynamic state. The new proposal can help the surgeons to put the management plan.

CPB

cardiopulmonary bypass

TEE

trans-esophageal echo

left ventricle

Ethical Approval

The patient has been consented for scientific research and publication

Competing interests

Nill

Authors' contributions

Hazem wrote the main manuscript and add a new proposal

Hani prepared Figures

Prof Ohri contributes in writing

All authors reviewed the manuscript.

Funding

Nill

Availability of data and materials

Not applicable.

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No competing interests reported.

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Left atrial dissection : An unique complication of mitral valve surgery

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Abstract

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Introduction

Case presentation

Discussion and Conclusions

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