Mechanisms of hemolysis after mitral valve repair: assessment by serial echocardiography
Tiong Cheng Yeo, MRCPb,
William K. Freeman, MD, FACCb,
Hartzell V. Schaff, MD, FACCa and
Thomas A. Orszulak, MD, FACCa
a Division of Cardiovascular Diseases and Cardiovascular Surgery, Rochester, Minnesota, USA
b Mayo Clinic and Mayo Foundation, Rochester, Minnesota, USA
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Figure 1 Collision mechanism of hemolysis. Follow-up inverted longitudinal multiplane TEE imaging. (A) Central mitral leaflet coaptation is mildly attenuated (large arrow) after mitral repair with Cosgrove-Edwards ring annuloplasty. A cross-section of the ring (arrowhead) with suture material (small arrow) is seen. (B) Color Doppler imaging reveals a jet of mitral regurgitation (large arrow) which immediately collides with the annuloplasty ring (arrowhead), redirecting the jet at an acute angle into the central LA (small arrows).
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Figure 2 Acceleration mechanism of hemolysis. Parasternal long-axis TTE imaging. (A) Mitral leaflet coaptation is intact status-post repair with neochordal implantation (small arrows) and St. Jude Biflex ring annuloplasty (arrowheads) three months earlier. (B) Color Doppler imaging in early systole reveals a thin jet of mitral regurgitation (large arrows) tracking around the lateral aspect of the annuloplasty ring. Regurgitant blood flow acceleration through this narrow zone of ring dehiscence accounted for the hemolysis.
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Figure 3 Fragmentation mechanism of hemolysis. Transverse plane TEE imaging. (A) Mild override of the anterior mitral valve leaflet (large arrow) is observed following triangular resection and chordal shortening of this leaflet with Duran ring annuloplasty (arrowhead) three months earlier. (B) Color Doppler imaging demonstrates bisection of a laterally directed mitral regurgitant jet (large arrows), divided by a minimally dehisced portion of the annuloplasty ring (arrowhead).
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Figure 4 Slow deceleration mitral regurgitation associated with nonhemolytic failure of mitral valve repair. Off-axis transverse plane TEE imaging. (A) Gross dehiscence (large arrow) of the lateral aspect of a Duran annuloplasty ring (arrowheads) placed 13 months earlier is readily evident. (B) The para-ring defect is so large that prominent diastolic inflow (large arrow), entering the LV adjacent to the annuloplasty ring (arrowheads), is present on color Doppler imaging. (C) During systole, a large regurgitant volume is entrained (small arrows) into the para-ring site of dehiscence on the ventricular aspect of the annuloplasty ring (arrowheads) and a broad eccentric jet of mitral regurgitation (large arrows) adheres to the lateral freewall of the LA. No hemolysis was caused by this type of regurgitant jet as rapid flow acceleration did not occur through this large regurgitant orifice.
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Figure 5 Central free jet mitral regurgitation present in nonhemolytic failure of mitral repair. Inverted transverse plane TEE imaging. (A) Incomplete central mitral leaflet coaptation (large arrow) is present 4 months after posterior leaflet quadrangular resection and Duran ring annuloplasty (arrowheads). (B) Severe central mitral regurgitation (large arrows) is detected by color Doppler imaging.
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