Paravalvular Leak After Mitral Valve Replacement or Another Source for a Regurgitant Jet?

Published:November 29, 2021DOI:
      A 73-YEAR-OLD man (height: 169 cm, weight: 55kg), with a history of mitral valve repair, tricuspid annuloplasty, and Maze procedure, presented to the authors' emergency department with an 8-day history of profound fatigue. Multiple blood cultures grew Streptococcus dysgalactiae. Transesophageal echocardiography (TEE) showed vegetations on the anterior mitral valve leaflet and mild-to-moderate mitral regurgitation. He was started on intravenous antibiotics (ampicillin and clindamycin) for a diagnosis of infectious endocarditis, but he did not improve. Magnetic resonance imaging indicated acute cerebral infarction during the patient's hospital course. Repeat TEE showed worsening mitral regurgitation and enlarging mitral valve vegetations. As a result, the patient was taken to the operating room for redo mitral valve replacement, maze procedure, and left atrial appendage (LAA) ligation. Intraoperative TEE confirmed the presence of vegetations on both the anterior leaflet and annuloplasty ring. The native mitral valve was excised and replaced with a 31-mm bioprosthesis. LAA ligation also was performed. After weaning from cardiopulmonary bypass, a modified midesophageal long-axis view with color Doppler imaging demonstrated abnormal blood flow near the bioprosthetic valve (Fig 1; Video 1). What is the diagnosis?
      Fig 1
      Fig 1A modified midesophageal long-axis view with color Doppler imaging of the left atrium showing abnormal blood flow from the left atrial wall near the bioprosthetic mitral valve.


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