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• W2017605724 abstract "We report the case of 50 year-old woman who presented with left ventricle outflow tract obstruction with discrete sub-aortic membrane 20 years following mitral valve replacement and tricuspid valve annuloplasty.We aim through this case, on one hand to report this unusual entity and on the other hand to discuss the underlying mechanisms as well as the therapeutic solutions. We report the case of 50 year-old woman who presented with left ventricle outflow tract obstruction with discrete sub-aortic membrane 20 years following mitral valve replacement and tricuspid valve annuloplasty. We aim through this case, on one hand to report this unusual entity and on the other hand to discuss the underlying mechanisms as well as the therapeutic solutions. We report the case of 50 year-old woman, with a history of mitral valve replacement and tricuspid valve annuloplasty 20 years ago, who was admitted for acute heart failure. The patient had On-X Conform-X bileaflet mitral valve prosthesis. At admission, she was orthopnoeic. Physical exam noted systolic murmur in both aortic and tricuspid areas. Signs of right heart failure were evident. Pulmonary auscultation revealed diffuse end-inspiratory crackles and right pleural effusion. At ECG, the patient was in atrial fibrillation. Chest X-ray showed enlarged cardiac shadow with alveolar oedema and moderate right pleural effusion. Trans-thoracic echocardiography revealed significant aortic stenosis, grade II aortic insufficiency as well as left ventricle outflow tract obstruction (LVOTO). Continuous wave Doppler detected significant systolic LVOT jets at 5 m/s. While mitral prosthesis showed no dysfunction, tricuspid valve was severely regurgitant. The left ventricle was hypertrophied and showed a preserved systolic function. [Fig. 1]. After a few days of medical therapy, the patient underwent surgery. The procedure was performed through a full sternotomy and under mild hypothermic cardiopulmonary bypass. After resection of the diseased aortic leaflets, we inspected the LVOT which was obstructed with a discrete sub-aortic membrane [Fig. 2]. The latter was completely excised to enlarge the LVOT. Then, we were able to observe the protrusion of the mitral prosthesis. There was no residual mitral leaflet tissue or chordae tendinae. The tricuspid valve ring was partially dehiscent. The aortic valve was replaced using a 19 size mechanical prosthesis and the tricuspid valve re-repaired using a 32 mm tri-dimensional ring. Aortic cross-clamping and CPB durations were respectively 70 min and 100 min. The subsequent course was uneventful. Postoperative control showed satisfactory outcomes. At six-month follow-up, she was doing well. Late development of LVOTO after MVR has already been reported, but it still remains an unusual condition particularly in the presence of discrete sub-aortic membrane [1Wu Q. Zhang L. Zhu R. Obstruction of Left Ventricular Outflow Tract After Mechanical Mitral Valve Replacement.Ann Thorac Surg. 2008; 85: 1789-1791Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar, 2Khoshnevis R. Barasch E. Pathan A. Christy G.W. Massumi G.A. Ott D.A. et al.Echocardiographic Diagnosis of Left Ventricular Outflow Tract Obstruction Caused by an Acquired Subaortic Membrane After Mitral Valve Replacement.J Am Soc Echocardiogr. 1999; 12: 319-323Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar]. In contrast to dynamic obstruction observed following mitral valve repair, mitral valve replacement may induce a fixed LVOTO. The underlying mechanisms are multifactorial [[3]Okamoto K. Kiso I. Inoue Y. Matayoshi H. Takahashi R. Umezu Y. Left Ventricular Outflow Obstruction After Mitral Valve Replacement Preserving Native Anterior Leaflet.Ann Thorac Surg. 2006; 82: 735-737Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar]. While some authors think that the LVOTO is related to simple valve protrusion toward the septum, especially when an oversized high-profile valve is used in a relatively small ventricle [[2]Khoshnevis R. Barasch E. Pathan A. Christy G.W. Massumi G.A. Ott D.A. et al.Echocardiographic Diagnosis of Left Ventricular Outflow Tract Obstruction Caused by an Acquired Subaortic Membrane After Mitral Valve Replacement.J Am Soc Echocardiogr. 1999; 12: 319-323Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar], others involve the preservation of the anterior mitral leaflet which results in secondary anterior prosthesis displacement [[1]Wu Q. Zhang L. Zhu R. Obstruction of Left Ventricular Outflow Tract After Mechanical Mitral Valve Replacement.Ann Thorac Surg. 2008; 85: 1789-1791Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar] or even a projection of the tensor apparatus into the LVOT [[3]Okamoto K. Kiso I. Inoue Y. Matayoshi H. Takahashi R. Umezu Y. Left Ventricular Outflow Obstruction After Mitral Valve Replacement Preserving Native Anterior Leaflet.Ann Thorac Surg. 2006; 82: 735-737Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar]. The mitral prosthesis induced obstruction itself is not severe enough to induce immediate postoperative complications and the patients usually recover uneventfully and remain asymptomatic for a long time [1Wu Q. Zhang L. Zhu R. Obstruction of Left Ventricular Outflow Tract After Mechanical Mitral Valve Replacement.Ann Thorac Surg. 2008; 85: 1789-1791Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar, 2Khoshnevis R. Barasch E. Pathan A. Christy G.W. Massumi G.A. Ott D.A. et al.Echocardiographic Diagnosis of Left Ventricular Outflow Tract Obstruction Caused by an Acquired Subaortic Membrane After Mitral Valve Replacement.J Am Soc Echocardiogr. 1999; 12: 319-323Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar, 3Okamoto K. Kiso I. Inoue Y. Matayoshi H. Takahashi R. Umezu Y. Left Ventricular Outflow Obstruction After Mitral Valve Replacement Preserving Native Anterior Leaflet.Ann Thorac Surg. 2006; 82: 735-737Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar]. However, this mild obstruction results in turbulent flows in the LVOT and leads progressively to secondary extensive fibrous hyperplasia. Khoshnevis et al. emphasise the important role of the sub-aortic membrane in the pathogenesis of LVOTO as well as the importance of its early detection [[2]Khoshnevis R. Barasch E. Pathan A. Christy G.W. Massumi G.A. Ott D.A. et al.Echocardiographic Diagnosis of Left Ventricular Outflow Tract Obstruction Caused by an Acquired Subaortic Membrane After Mitral Valve Replacement.J Am Soc Echocardiogr. 1999; 12: 319-323Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar]. LVOTO becomes progressively significant and leads to left ventricular hypertrophy, which worsens the initial LVOTO. Our patient initially had rheumatic mitral stenosis. These patients usually have a tendency to present small aortic annulus and LV cavity and obviously small LVOT. Thus, they may be more predisposed to develop sub-aortic membrane. Also, turbulent flows may expose the aortic valve to excessive shear stress and accelerate degeneration process [[4]Oliver J.M. González A. Gallego P. Sánchez-Recalde A. Benito F. Mesa J.M. Discrete subaortic stenosis in adults: increased prevalence and slow rate of progression of the obstruction and aortic regurgitation.J Am Coll Cardiol. 2001; 38: 835-842Abstract Full Text Full Text PDF PubMed Scopus (128) Google Scholar]. Management of LVOTO following MVR is challenging mainly because of the advanced heart failure stage, the redo surgery and the eventual associated co-morbidities. Many therapeutic options can be considered. Authors suggest the change of the high profile mitral prosthesis [[2]Khoshnevis R. Barasch E. Pathan A. Christy G.W. Massumi G.A. Ott D.A. et al.Echocardiographic Diagnosis of Left Ventricular Outflow Tract Obstruction Caused by an Acquired Subaortic Membrane After Mitral Valve Replacement.J Am Soc Echocardiogr. 1999; 12: 319-323Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar], reinsertion of the prosthesis after the resection of the initially preserved leaflet [[1]Wu Q. Zhang L. Zhu R. Obstruction of Left Ventricular Outflow Tract After Mechanical Mitral Valve Replacement.Ann Thorac Surg. 2008; 85: 1789-1791Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar] or eventually cutting the redundant chordae tendinae through the aortic root [[3]Okamoto K. Kiso I. Inoue Y. Matayoshi H. Takahashi R. Umezu Y. Left Ventricular Outflow Obstruction After Mitral Valve Replacement Preserving Native Anterior Leaflet.Ann Thorac Surg. 2006; 82: 735-737Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar]. However, most of these mitral procedures may result in higher morbidity and mortality mainly in the setting of redo multiple valve surgery as in our case. Furthermore, these procedures alone, without resection of the sub-aortic membrane, may be insufficient to relieve LVOTO [[2]Khoshnevis R. Barasch E. Pathan A. Christy G.W. Massumi G.A. Ott D.A. et al.Echocardiographic Diagnosis of Left Ventricular Outflow Tract Obstruction Caused by an Acquired Subaortic Membrane After Mitral Valve Replacement.J Am Soc Echocardiogr. 1999; 12: 319-323Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar]. Indeed, some techniques are recommended. In patients with small left ventricle, mitral prosthesis over-sizing should be avoided and eventually posterior chordal preservation preferred. Total chordal preservation is technically feasible in only 50% of patients with rheumatic mitral stenosis. In these cases, the anterior leaflet should be carefully divided, shifted and reaffixed to not interfere with LVOT [3Okamoto K. Kiso I. Inoue Y. Matayoshi H. Takahashi R. Umezu Y. Left Ventricular Outflow Obstruction After Mitral Valve Replacement Preserving Native Anterior Leaflet.Ann Thorac Surg. 2006; 82: 735-737Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar, 5Chowdhury U.K. Kumar A.S. Airan B. Mittal D. Subramaniam K.G. Prakash R. et al.Mitral Valve Replacement With and Without Chordal Preservation in a Rheumatic Population: Serial Echocardiographic Assessment of Left Ventricular Size and Function.Ann Thorac Surg. 2005; 79: 1926-1933Abstract Full Text Full Text PDF PubMed Scopus (43) Google Scholar]." @default.
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• W2017605724 title "Mitral Valve Replacement as Unusual Cause of Discrete Sub-Aortic Membrane" @default.
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