Detailed Treatment Process
Female, 54 years old, underwent artificial aortic and mitral valve replacement surgery 16 years ago Recently hospitalized due to recurrent atrial fibrillation and other symptoms
This is the echocardiography report before the paravalvular leak closure procedure: (June 27) Department: Cardiology Examination Modes: M-mode, 2D echocardiography, Doppler (Pulsed Wave, Continuous Wave, Color Flow) I. Main measurements: (unit: mm) Name Measured value (normal value) Aortic root inner diameter 27 (20-37mm) Left ventricular end-systolic diameter 34 (20-37mm) Left ventricular end-diastolic diameter 55 (35-56mm) Left atrial inner diameter 57 (19-40mm) Interventricular septum thickness 11 (6-11mm) Left ventricular posterior wall thickness 11 (6-11mm) Main pulmonary artery 30 (19-27mm) III. Echocardiographic description: Compared with January 24 of the previous year: 1. Left atrial diameter slightly increased compared with before, left ventricular diameter similar to previous, still within normal range, left ventricular wall not thickened, left ventricular wall systolic motion normal at rest. 2. Aortic mechanical valve ring fixed, valve leaflets echo still clear, continuous Doppler estimated aortic peak transvalvular pressure gradient approximately 52mmHg, color Doppler did not detect significant paravalvular regurgitation. 3. Mitral mechanical valve paravalvular anterior-lateral quadrant showed separation of ring and paravalvular tissue echo about 4mm, valve ring mobility limited, valve leaflets opening and closing acceptable, continuous Doppler estimated opening area about 2.1cm2, color Doppler detected mild to moderate regurgitation at the paravalvular site. 4. Right atrial and ventricular diameters normal, pulmonary artery diameter widened, continuous Doppler estimated pulmonary artery systolic pressure about 52mmHg based on mild tricuspid regurgitation. 5. Remaining ultrasound findings same as before. IV. Conclusion: Post mitral and aortic mechanical valve replacement: Mitral mechanical valve paravalvular leak (mild to moderate regurgitation) No significant abnormality in mechanical valve function Pulmonary hypertension (moderate) Date: June 27
This is the echocardiography report for the paravalvular leak closure procedure: (July 8) Department: Cardiac Surgery Examination Modes: M-mode, 2D echocardiography, Doppler (Pulsed Wave, Continuous Wave, Color Flow) I. Main measurements: (unit: mm) Name Measured value Normal value Aortic root inner diameter 30 (20-37mm) Left ventricular end-systolic diameter 33 (20-37mm) Left ventricular end-diastolic diameter 53 (35-56mm) Left atrial inner diameter 50 (19-40mm) Interventricular septum thickness 11 (6-11mm) Left ventricular posterior wall thickness 11 (6-11mm) Main pulmonary artery 30 (19-27mm) III. Echocardiographic description: Compared with June 27: 1. Left atrial diameter still enlarged but slightly reduced compared with before, left ventricular diameter similar to previous, still within normal range, left ventricular wall not thickened, left ventricular systolic motion normal at rest. 2. Mitral mechanical valve paravalvular anterior-lateral quadrant showed occluder echo, normal morphology and fixed position, valve leaflets opening and closing normal, continuous Doppler estimated opening area about 2.1cm2, mean transvalvular pressure gradient about 4mmHg, color Doppler detected mild paravalvular regurgitation. 3. Right atrial and ventricular diameters normal, pulmonary artery still widened, color Doppler detected mild tricuspid regurgitation. 4. Remaining ultrasound findings same as before. IV. Conclusion: Post mitral and aortic valve replacement (DVR+MVR) and left-sided closure: mild mitral mechanical valve paravalvular regurgitation Date: July 8
In the above situation, the patient was hospitalized and underwent paravalvular leak closure and radiofrequency ablation. After the procedure, the patient felt generally unwell and had persistent sallow complexion. After discharge, she returned to the hospital for follow-up visits several times. Ultrasound examinations still showed mild to moderate paravalvular leak and regurgitation of the mitral and aortic mechanical valves as well as moderate pulmonary hypertension. Regarding the sallow complexion, after half a year of continuous visits, a doctor finally told the patient that the sallow complexion was caused by the paravalvular leak occluder. After the metal occluder was implanted in the heart, high-speed blood flow impacting red blood cells caused red blood cell fragmentation, leading to mechanical hemolysis and elevated bilirubin, thus resulting in severe hemolytic anemia. This was the cause of the sallow complexion. Afterward, the patient underwent "minimally invasive redo mitral valve replacement" at another hospital, but ultimately died in the perioperative period. The following is the surgical record: Next year February 7 20:57 Surgical record Surgery date: February 7 Surgery name: Minimally invasive redo mitral valve replacement Preoperative diagnosis: Post double valve replacement; post mitral moderate paravalvular leak closure; moderate pulmonary hypertension; persistent atrial fibrillation; hemolytic anemia; hyperbilirubinemia Intraoperative diagnosis: Post double valve replacement; post mitral moderate paravalvular leak closure; moderate pulmonary hypertension; persistent atrial fibrillation; hemolytic anemia; hyperbilirubinemia Anesthesia method: General anesthesia Surgical procedure: Incision: Right chest 4th intercostal space Patient position: Right side elevated 30 degrees Right pleura ruptured, adhesions inside the thoracic cavity, no pleural effusion Pericardium (with) adhesions, (no) effusion. Heart enlargement: Right atrium +, right ventricle +, left atrium ++, left ventricle ++, Pulmonary artery diameter (___) cm, aortic diameter (___) cm. Thrill locations: Systolic (+, ++, +++) locations Diastolic (+, ++, +++) locations Finger exploration findings: Not explored Left atrial incision: Via interatrial groove, length 4 cm. Left atrium (no) thrombus Mitral valve lesion: Artificial mechanical mitral valve opening unrestricted, paravalvular granulation tissue proliferation, about 1/2 circumference of artificial valve and annulus with paravalvular leak, occluder visible inside, occluder removed intraoperatively, artificial valve excised along the annulus. After valve excision: Annulus diameter: 2.8 cm Selected artificial heart valve: Mechanical valve Selected valve type: Inner diameter cm, outer diameter 2.7 cm ST. JUDE valve Valve suturing method: Mitral: Pledgeted interrupted mattress sutures Mitral total 13 sutures Valve frame placed: In the annulus Additional procedures: Left atrial incision closure method: 3-0 Prolene continuous 2 layers Pericardial closure method: Drainage tube placement method: One right chest drainage tube Chest incision closure method: Interrupted 1 layer, continuous 2 layers