A 54-year-old female, a known case of rheumatic heart disease with severe mitral stenosis, MV area was 0.9 cm2, and moderate mitral regurgitation, was admitted to our hospital. The MV and subvalvular apparatus were calcified and there was moderate pulmonary arterial hypertension. Bilateral ventricular functions were within normal limits. She was posted for MV replacement (MVR) and informed consent was obtained. Her preoperative hematological investigations were within normal limits. General anesthesia was induced with standard medications and cardiopulmonary bypass (CPB) was established.\nShe underwent MVR with bioprosthetic valve 25 mm (EPIC, St. Jude Medical). Immediate post-CPB TEE showed normal functioning prosthetic valve and Doppler also revealed normal pressure gradients across the valve []. Her intraoperative period was uneventful and shifted to postoperative Intensive Care Unit (ICU) with minimal doses of inotropes. Postoperative day (POD) 0 was uneventful; however, on POD 1, she developed hypotension (arterial pressure 84/50 mmHg) that required increasing doses of inotropic support. Her central venous pressure was 20 mmHg and pulmonary artery pressure was 60/38 mmHg. Arterial blood gases also revealed metabolic acidosis. Due to her hemodynamic status, she could not be weaned off the mechanical ventilation.\nTEE was done to rule out cardiac tamponade and to evaluate the prosthetic MV function. It revealed a large cavitatory mass occupying the whole of left atrium (LA) which was obliterating the movement of MV leaflets [ and ]. Continuous wave Doppler (CWD) showed pressure gradient (peak/mean) of 19/10 mmHg across MV []. However, bilateral ventricular functions were within normal limits.\nOwing to her deteriorating hemodynamic condition, she was immediately shifted to the operating room. Chest was reopened and CPB was established. Opening of LA revealed dissection of the LA wall extending from the posterior annulus of the MV to the roof of LA. Clots were removed from the LA; however, the cavity again filled up. Therefore, it was decided to do the “marsupialization” for clearing of the cavity [ and ]. The bioprosthetic valve was also examined and was found to be normal. CWD also revealed normal gradient across prosthetic MV []. The patient was weaned off the CPB with low dose of inotropes. She was mechanically ventilated for 24 h and inotropes were gradually weaned off. She had longer stay in the ICU; otherwise her postoperative period was uneventful.
A 55-year-old man presented with rheumatic heart disease, severe mitral regurgitation, moderate pulmonary arterial hypertension, and good biventricular function. He was scheduled for mitral valve replacement (MVR). After applying standard monitors and preoxygenation, general anesthesia was induced with 2 mg of midazolam, 50 mg of propofol, 200 μg of fentanyl, 60 mg of lidocaine, and 8 mg of vecuronium. Anesthesia was maintained with oxygen: Air, 1% isoflurane, and intermittent doses of fentanyl. The trachea was intubated with an 8.5-mm single-lumen tracheal tube. A right femoral arterial catheter was placed for continuous blood pressure monitoring.\nMVR with 29 mm St. Jude mechanical prosthetic valve with posterior mitral leaflet preservation was performed through transseptal approach on conventional cardiopulmonary bypass (CPB) and cold blood cardioplegia. The patient was weaned off CPB with the optimal inotropic support of 5 μg/kg/min of dopamine and 5 μg/kg/min dobutamine. But, the pressures were on borderline around 80/38 mmHg, and right ventricle appears to be distending with poor myocardial contractions. So, we decided to put transesophageal echocardiography (TEE) probe to see for any abnormality. To our surprise, we saw a circular hypoechoic mass in the left atrial (LA) free wall encroaching onto the mitral valve []. This finding was discussed with the surgeon, who decided to re-explore the LA. LA atriotomy was reopened, the mitral valve appeared to be well seated, and there was no evidence of dissection. Only the LA free wall appeared to have subendocardial blood collection. There were no continuities between the cavity and the LA, left ventricle, posterior pericardial space. Marsupialization of the cavity is done and opened it to the LA cavity [].\nThe patient was then weaned from CPB for the 2nd time with inotropic support of 0.375 μg/kg/min of milrinone, 5 μg/kg/min of dopamine, 5 μg/kg/min dobutamine, and 0.05 μg/kg/min of nor epinephrine. The post-bypass TEE examination showed that LA dissection (LAd) wall appeared to be incised in the middle and drained out the blood.\nThe patient's postoperative course was complicated by intermittent periods of desaturation which required bi-level airway pressure ventilation with which he showed improvement in oxygenation. The patient was discharged from the hospital 15 days after surgery.