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ORIGINAL ARTICLE

Ventricular disruption after mitral valve replacement

Marcelo Campos ChristoI; Liberato S. Siqueira de SouzaII; Marcílio José StortiniII; Sérgio L. da Costa TeixeiraII; Osvaldo Cruz JúniorII

DOI: 10.1590/S0102-76381989000100008

ABSTRACT

Between 1979 and 1988 four fatal cases of left ventricular disruption after mitral valve replacement were registered among 332 patients submitted to mitral valve replacement, with two different types of porcine prosthesis in isolated or combined operations. All patients were elderly women (mean age 58) with predominant mitral insufficiency. Complications occurred after isolated MVR in 3 patients and in 1 patient after MVR combined with coronary artery by-pass. Damage appeared to have been caused by rhythmical pulling exerted by sorrounding myocardium against a hypocinetic ventricular wall locally ischemic by compression of a viciously positioned prosthesis. The mis-evaluation of the mitral annulus was induced by the usage of innadequate sizers used in profoundly relaxed heart under cardioplegia. The profile of the prosthesis probably influenced the type of lesion. Modifications in the sizer's head and the usage of flexible and malleable sizer-holders, that could permit a more accurate position of sizer's head in the mitral annulus are suggested. Possible etiological co-factors are: elderly patients, particularly women, with myocardial lesions secondary to overzealous resection of papillary posterior muscle or of the mitral cusp, and the loss of the internal buttress of the myocardium after resection of subvalvar apparatus (untethered ventricle). Preserving chordae tendinae of the annulus of mural leaflet could help the prevention of these complications.

RESUMO

Entre 1979 e 1988, 4 casos de rotura do ventrículo esquerdo (VE), após substituição da valva mitral (SVM), foram registrados entre 332 pacientes. Os autores reconhecem, entre seus casos, 3 roturas na junção atrioventricular, ocorridas logo após a saída de by-pass e 1 rotura em parede posterior do VE, ocorrida na unidade de terapia intensiva (UTI). Os pacientes eram todos do sexo feminino e tinham, em média, 58 anos de idade. Tais acidentes aconteceram 3 vezes após substituição isolada da valva mitral e 1 vez em operação combinada de SVM e revascularização do miocárdio. Admitem que o mecanismo principal da rotura está ligado à criação de zona de acinesia isquêmica, localizada em parede do VE, secundária à superdistensão de anel mitral. Relacionam o desencadeamento dos acidentes com a superdistensão dos anéis valvares, avaliados com medidores inadequados, usados em corações profundamente relaxados pela cardioplegia. Preconizam modificações na cabeça desses medidores, adaptando-os a cabos maleáveis, de modo a permitir um posicionamento mais perfeito da cabeça do medidor do anel mitral. Admitem que o perfil mais ou menos elevado das próteses não parece haver influenciado no aparecimento, ou na prevenção desses acidentes, mas sim na determinação do tipo anatômico da lesão. Estão de acordo com outros autores, quando admitem que a fragilidade do miocárdio, em pacientes idosos, agravada com a remoção do aparelho valvar mitral (ventrículo sem sustentação), criaria condições para o aparecimento desses acidentes. Consideram desejável a preservação do aparelho valvar mitral nas SVM, mas consideram que técnicas seguras, com essa finalidade, precisam ser ainda desenvolvidas.
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