title: Elevated transaortic valvular gradients after combined aortic valve and mitral valve replacement: an intraoperative dilemma.
abstract: High transaortic valvular gradients, after combined aortic valve and mitral valve replacement, require prompt intraoperative diagnosis and appropriate management. The presence of high transaortic valvular gradients after cardiopulmonary bypass, in this setting, can be secondary to the following conditions: prosthesis dysfunction, left ventricular outflow tract obstruction, supravalvular obstruction, prosthesis-patient mismatch, hyperkinetic left ventricle from administration of inotropes, left ventricular intracavitary gradients, pressure recovery phenomenon, and increased transvalvular blood flow resulting from hyperdynamic circulation or anemia. Transesophageal echocardiography is an extremely useful tool for timely diagnosis and treatment of this complication. We describe a case of a critically ill patient with endocarditis and acute lung injury, who presented for combined aortic valve and mitral valve replacement. Transesophageal echocardiographic assessment, post-cardiopulmonary bypass, revealed high transaortic valvular gradients due to encroachment of the mitral prosthesis strut on the left ventricular outflow tract, which was compounded by a small, hypertrophied, and hyperkinetic left ventricle. Discontinuation of inotropic support, administration of fluids, phenylephrine, and esmolol led to resolution of the high gradients and prevented further surgery.
authors.affiliation: Ohio State University, Columbus, OH, USA michael.essandoh@osumc.edu.
authors.forename: Michael
authors.initials: M
authors.lastname: Essandoh
authors.affiliation: Ohio State University, Columbus, OH, USA.
authors.forename: Juan
authors.initials: J
authors.lastname: Portillo
authors.affiliation: Ohio State University, Columbus, OH, USA.
authors.forename: Alix
authors.initials: A
authors.lastname: Zuleta-Alarcon
authors.affiliation: Ohio State University, Columbus, OH, USA.
authors.forename: Karina
authors.initials: K
authors.lastname: Castellon-Larios
authors.affiliation: Ohio State University, Columbus, OH, USA.
authors.forename: Andrew
authors.initials: A
authors.lastname: Otey
authors.affiliation: Ohio State University, Columbus, OH, USA.
authors.forename: Chittoor B
authors.initials: CB
authors.lastname: Sai-Sudhakar
mesh_terms: D000368:Aged; D001021:Aortic Valve / Q000601:surgery*; D002315:Cardiopulmonary Bypass / Q000379:methods; D016638:Critical Illness; D017548:Echocardiography, Transesophageal; D019918:Heart Valve Prosthesis Implantation / Q000009:adverse effects / Q000379:methods*; D006801:Humans; D007430:Intraoperative Care / Q000379:methods; D008297:Male; D008943:Mitral Valve / Q000601:surgery*; D014694:Ventricular Outflow Obstruction / Q000150:complications
keywords: aortic valve replacement; bioprosthetic mitral valve; left ventricular outflow tract obstruction; mitral valve replacement; prosthesis-patient mismatch; transaortic valve gradients; transesophageal echocardiography