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Journal of Investigative Medicine High Impact
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Mitral Valve Annuloplasty Ring Dehiscence Diagnosed Intraoperative With Real-Time 3D Transesophageal
Echocardiogram
Karina Castellon-Larios, Alix Zuleta-Alarcon, Antolin Flores, Michelle Humeidan, Andrew N. Springer and Michael Essandoh
Journal of Investigative Medicine High Impact Case Reports 2014 2:
DOI: 10.1177/2324709614538822
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HICXXX10.1177/2324709614538822Journal of Investigative Medicine High Impact Case ReportsCastellon-Larios et al
Article
Mitral Valve Annuloplasty Ring

Dehiscence Diagnosed Intraoperative
With Real-Time 3D Transesophageal
Echocardiogram
Journal of Investigative Medicine High

Impact Case Reports
13
2014 American Federation for
Medical Research
DOI: 10.1177/2324709614538822
hic.sagepub.com
Karina Castellon-Larios, MD1, Alix Zuleta-Alarcon, MD1, Antolin Flores, MD1,

Michelle Humeidan, MD, PhD1, Andrew N. Springer, MD1, and Michael Essandoh, MD1
Abstract
Mitral annular calcification (MAC) is often a result of the accumulation of lipids around the annulus, which can lead to
degeneration and calcification of the valve. Multiple risk factors have been associated with the progression of MAC and lifethreatening complications such as the early mitral valve annuloplasty dehiscence. Our case describes the different risk factors
for annuloplasty dehiscence in a patient with severe MAC, as well as the importance of its early recognition intraoperatively
with 3D transesophageal echocardiography.
Keywords
mitral valve calcification, annuloplasty ring dehiscence, 3D echocardiography
Introduction
Mitral regurgitation (MR) and mitral annular calcification
(MAC) are common conditions in middle-aged and elderly
population with a prevalence of 2% and 8%, respectively.
Mitral valve regurgitation is commonly associated with left
ventricular remodeling, secondary to coronary artery disease, and hypertension, among others. MAC risk factors
include both factors mentioned above, as well as Caucasian
race, female gender, hyperlipidemia, diabetes, current or past
history of smoking, atherosclerosis, chronic renal insufficiency, and high levels of interleukin-6, which may lead to
all-cause mortality.1-3
Mitral valve repair is the treatment of choice for MR and
leads to better preservation of left ventricular function and
survival.4 Real-time 3D transesophageal echocardiogram
provides a detailed image of mitral valve pathology, mechanism of MR, and severity.5 This better understanding of the
MR pathophysiology and the alteration of annular geometry
has contributed to better repair techniques and the placement
of etiology-specific rings, which are specially challenging
when MR is accompanied by MAC.4
Case Presentation
A 69-year-old Caucasian female with a past medical history
significant for polycystic kidney disease requiring a cadaveric
kidney transplant, hypertension, hyperlipidemia, coronary
artery disease and MR, was transferred to our institution for

triple vessel coronary artery bypass graft (CABG) and mitral
valve repair.
She had presented to an outside hospital with angina at
rest and worsening dyspnea on exertion. She underwent cardiac catheterization, which showed severe multivessel coronary artery disease, including a nearly completely occluded
right coronary artery with some collateral filling from the
left, high-grade proximal left anterior descending (LAD)
lesion, as well as circumflex arterial lesions in the first and
second obtuse marginals.
Transthoracic echocardiogram performed at our institution revealed moderate to severe left ventricular systolic dysfunction with an estimated ejection fraction of 25% to 30%,
diastolic filling pattern consistent with Grade II diastolic
dysfunction (pseudonormalization), moderate concentric left
ventricular hypertrophy, regional wall motion abnormalities,
moderate ischemic MR, and moderate to severe MAC.
The patient was taken to the operating room and general
anesthesia was induced uneventfully under multichannel
1
The Ohio State University Wexner Medical Center, Columbus, OH, USA
Corresponding Author:
Michael Essandoh, MD, Department of Anesthesiology, Division of
Cardithoracic and Vascualr Anesthesiology. The Ohio State University
Wexner Medical Center 410 W. 10th Avenue, Columbus, OH 43210,
USA.
Email: michael.essandoh@osumc.edu
Journal of Investigative Medicine High Impact Case Reports
Figure 1. Two-dimensional transesophageal echocardiography

midesophageal 4-chamber view showing dehiscence of the
annuloplasty ring.
Abbreviation: A, mitral annulus.
invasive monitoring. Intraoperative transesophageal echocardiogram (TEE) was performed with a 3D matrix-array
probe (X7-2t transducer; Philips Healthcare, Andover, MA)
that showed similar results as the preoperative transthoracic
echocardiogram except for moderate to severe central MR.
The patient underwent an uneventful triple vessel CABG
(left internal mammary artery to her LAD, saphenous vein
graft to a dominant obtuse marginal, and saphenous vein graft
to her acute marginal), as well as a mitral valve repair with a
size 26 mm St Jude annuloplasty ring. Post bypass 2D TEE
assessment showed an echodense structure in the mitral annulus close to the aorto-mitral curtain without any MR on color
flow Doppler (Figures 1 and 2). The absence of MR was likely
due to occlusion of the orifice between the annulus and the
ring during systole by the anterior mitral valve leaflet. Threedimensional TEE was then performed, revealing partial ring
dehiscence and deformation of the annuloplasty ring along the
anterior aspect of the mitral annulus. A clear diagnosis of
mitral valve annuloplasty dehiscence was made (Figure 3).
Discussion
Chronic renal insufficiency has been shown to promote calcium accumulation in cardiovascular structures, including
the mitral annulus in up to 31% of patients.6 Movva et al.
systemically evaluated the mitral valve and annular calcification in patients with chronic kidney disease and on hemodialysis. They observed MAC to be prevalent in this patient
population and found it to be associated with MR than MS.7
The Role of Echocardiography in Mitral Pathology

Real-time 3D TEE is a valuable tool in the diagnosis of heart
disease, especially for mitral valve pathology, its optimal
Figure 2. Two-dimensional transesophageal echocardiography

midesophageal 5-chamber view showing dehiscence of the
annuloplasty ring, with the ring causing echo dropout. The red
arrow shows the anterior mitral valve leaflet, and the green
arrow shows the posterior mitral valve leaflet.
Abbreviations: S, interventricular septum; RV, right ventricle; LV, left
ventricle.
localization, extension, and mechanism.8 Kronzon et al.

demonstrated that 3D TEE provides detailed information
regarding the size, shape, and area of the dehisced segment,
when compared with 2D TEE in the diagnosis of mitral valve
annuloplasty and prosthetic valve dehiscence.9 In other clinical scenarios, 3D TEE has been shown to be accurate and
concordant with surgical and catheterization findings in
mitral valve stenosis orifice area calculation, functional anatomy of MR, and evaluation of prolapsing mitral valve scallops. Furthermore, in the diagnosis of complex pathologies,
3D TEE also provides optimal spatial resolution and capability to precisely describe the characteristics of native and
prosthetics valves.8,10,11
In our case, 3D TEE allowed for a precise intraoperative
diagnosis of a segmental separation between the native mitral
valve annulus and the prosthetic ring at the aorto-mitral curtain. Three-dimensional TEE simplifies communication and
visualization of echocardiographic findings between the
anesthesiology and surgical teams. In emergent as well as
nonemergent procedures, it provides a prompt and accurate
diagnosis of mitral valve pathology for immediate decision
making and treatment.12 Real-time 3D TEE constitutes a
powerful tool to plan the appropriate interventional approach
and identify concomitant cardiac pathologies. 9,13
Conclusion
Although 2D TEE is currently the standard of care for intraoperative assessment after valve surgery, especially mitral
valve pathology, it is well documented throughout the literature that there are several limitations to this approach.14 Realtime 3D TEE is a new approach to intraoperative assessment
Castellon-Larios et al
Figure 3. En face view 3D transesophageal echocardiography

illustrating the anterior defect of the annuloplasty ring at the
aorto-mitral curtain, through the defect the precise location of
the anterior mitral valve leaflet is readily apparent (arrow head).
after valve surgery and is still not considered standard of care

for these or any other type of procedures. Nonetheless, it is a
very accurate method for detection of intraoperative complications, including annuloplasty dehiscence, when the 2D
TEE results are inconclusive.
Declaration of Conflicting Interests
The author(s) declared no potential conflict of interests with respect
to the research, authorship, and/or publication of this article.
Funding
The author(s) received no funding support for the research, authorship, and/or publication of this article.
References
1. Ramaraj R, Manrique C, Hashemzadeh M, Movahed MR.
Mitral annulus calcification is independently associated with
all-cause mortality. Exp Clin Cardiol. 2013;18(1):e5-e7.
2. Elmariah S, Budoff M, Delaney J, et al. Risk factors associated
with the incidence and progression of mitral annulus calcification: the multi-ethnic study of atherosclerosis. Am Heart J.
2013;166:904-912.
3. Rossi A, Faggiano P, Amado AE, et al. Mitral and aortic valve

sclerosis/calcification and carotid atherosclerosis: results from
1065 patients [published online November 7, 2013]. Heart
Vessels. doi:10.1007/s00380-013-0433-z.
4. Curtin RJ, Griffin BP. Mitral disease: stenosis and regurgitation. The Cleveland Clinic Disease Management Project.
http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/cardiology/mitral-valve-disease/#top. Published
August 2010. Accessed March 31, 2014.
5. Silbiger JJ. Anatomy, mechanics, and pathophysiology of the
mitral annulus. Am Heart J. 2012;164:163-176.
6. Acker MA, Parides MK, Perrault LP, et al. Mitral-valve repair
versus replacement for severe ischemic mitral regurgitation. N
Engl J Med. 2014;370:23-32.
7. Movva R, Murthy K, Romero-Corral A, Seetha Rammohan
HR, Fumo P, Pressman GS. Calcification of the mitral valve
and annulus: systematic evaluation of effects on valve anatomy
and function. J Am Soc Echocardiogr. 2013;26:1135-1142.
8. Hahn RT, Abraham T, Adams MS, et al. Guidelines for performing a comprehensive transesophageal echocard-iographic
examination: recommendations from the American Society
of Echocardiography and the Society of Cardiovascular
Anesthesiologists. J Am Soc Echocardiogr. 2013;26:921-964.
9. Kronzon I, Sugeng L, Perk G, et al. Real-time 3-dimensional
transesophageal echocardiography in the evaluation of postoperative mitral annuloplasty ring and prosthetic valve dehiscence. Coll Cardiol. 2009;53:1543-1547.
10. Mor-Avi V, Sugeng L, Lang RM. Real-time 3-dimensional
echocardiography: an integral component of the routine echocardiographic examination in adult patients? Circulation.
2009;119:314-329.
11. Garca-Orta R, Moreno E, Vidal M, et al. Three-dimensional
versus two-dimensional transesophageal echocardiography in
mitral valve repair. J Am Soc Echocardiogr. 2007;20:4-12.
12. Ciobanu AO, Griffin SC, Bennett S, Vinereanu D. Catastrophic
mitral prosthesis dehiscence diagnosed by three-dimensional transesophageal echocardiography. J Clin Ultrasound.
2014;42:249-251.
13. Ghadimi K, Gosalia AR, Troianos CA. Echo rounds: intraoperative delineation of mitral annuloplasty dehiscence using
three-dimensional transesophageal echocardiography. Anesth
Analg. 2011;113:1013-1015.
14. Hien MD, Rauch H, Lichtenberg A, et al. Real-time threedimensional transesophageal echocardiography: improvements in intraoperative mitral valve imaging. Anesth Analg.
2013;116:287-295.

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Journal of Investigative Medicine High Impact

American Federation for Medical Research

>> Version of Record - Jun 24, 2014

HICXXX10.1177/2324709614538822Journal of Investigative Medicine High Impact Case ReportsCastellon-Larios et al

Mitral Valve Annuloplasty Ring

Journal of Investigative Medicine High

Karina Castellon-Larios, MD1, Alix Zuleta-Alarcon, MD1, Antolin Flores, MD1,

artery disease and MR, was transferred to our institution for

Journal of Investigative Medicine High Impact Case Reports

Figure 1. Two-dimensional transesophageal echocardiography

The Role of Echocardiography in Mitral Pathology

Figure 2. Two-dimensional transesophageal echocardiography

localization, extension, and mechanism.8 Kronzon et al.

Figure 3. En face view 3D transesophageal echocardiography

after valve surgery and is still not considered standard of care

3. Rossi A, Faggiano P, Amado AE, et al. Mitral and aortic valve

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