Case
A 55-year-old male patient was admitted to the outpatient clinic with
intolerable dyspnea which occurs with minimal effort. He had a mitral
repair with a Memo annuloplasty ring due to a severe mitral
regurgitation (MR) associated with annular dilation caused by atrial
fibrillation 3 years ago and there was no residual MR in the
postoperative echocardiography. Transthoracic echocardiography revealed
normal left ventricular ejection fraction (%55) and moderate-severe MR.
Transesophageal echocardiography (TEE) was decided as a next step to
clarify the mechanism of the mitral regurgitation (MR). Rocking
prosthetic ring and dehiscence were present in the mid-esophageal two-
and three-dimensional TEE views respectively with a severe mitral
regurgitation (figure 1a, video 1, 2). There were two mitral
regurgitation jets. It was observed that in the mid-esophageal TEE
views, the first jet was originating from the perimitral ring and the
second jet was arising from the basal portion of the posterior mitral
leaflet which was suitable with the location of the mitral ring
suture(figure 1b, video 3). Interestingly, dehiscence of the mitral ring
possibly caused the occurrence of a defect in the posterior mitral
leaflet in the junction zone and this defect emerged as another source
of MR(figure 1c-1d, video 4). Surgical treatment was planned for the
patient due to the presence of NYHA class III symptoms and severe MR.
Ring annuloplasty is mainly used to fix MR caused by the geometrical
changes in the left ventricle which may result in annular dilation. Ring
dehiscence is a rare clinical entity that usually leads to severe MR and
requires urgent or emergent surgical reoperation(1). Endocarditis,
trauma, or procedure-related issues may be responsible to trigger the
dehiscence process and progressive left ventricular geometric remodeling
may also provoke recurrence (2,3). Characteristics of the tissue at the
ring attachment areas are another important factor so, weak and
calcified tissues are more prone to separation from the ring(3).
Furthermore, attachment of the mitral ring to the basal portion of the
PML in the previous surgery may cause a predisposition to ring
dehiscence, and the suture site on the PML behaved as an independent
source of MR besides the regurgitation jet from the perimitral ring. In
this case, two- and three-dimensional echocardiographic demonstrative
images are presented to highlight this rare clinical condition.