Iatrogenic mitral regurgitation
B. Consult cardiovascular surgery to discuss mitral valve surgery
The key to the correct diagnosis in this patient was the transesophageal echocardiogram revealing a new, severe, eccentric, posteriorly directed jet of MR and flail segment of the A3 anterior aortic leaflet (Figure). Recognition of the pVAD as a potential cause of iatrogenic MR is important, as acute severe MR requires prompt early surgical intervention.
Frequent complications after pVAD placement include thrombus formation, tamponade, right ventricular failure, and hypovolemia. To our knowledge, there have been very few case reports of iatrogenic MR in patients with pVAD.1,2 Possible mechanisms of injury are damage to the mitral valve apparatus during the insertion of pVAD or subsequent migration of the device. In fulminant myocarditis, it is hypothesized that the myocardial tissue is inflamed and friable, making it more susceptible to injury.3 In this patient, the pVAD was placed emergently when the patient was hemodynamically unstable. While receiving ECMO support, the complete hemodynamic effect of MR is usually not apparent owing to the altered physiology. Severe MR and flail leaflet were only apparent after ECMO decannulation.