Partial detachment of mitral valve annuloplasty ring and evaluation with real-time 3D-transesophageal echocardiography

Mitral ring annuloplasty (MRA) is commonly considered as a treatment for those who require surgical revascularization due to coronary artery disease concomitant with moderate or severe mitral regurgitation (MR). In addition, the selection of an appropriate ring size is of importance in patients who undergo MRA. Moderate or severe MR may be an important issue with the use of partial detachment of small sized rings. A 68-year-old male with a history of coronary artery bypass surgery 15 years and 5 years ago and MRA (29-mm Duran ring) for MR during the second surgery was referred to our clinic because of symptomatic severe MR. Transthoracic echocardiography demonstrated a dilated left ventricle with depressed systolic function and severe MR. Transesophageal echocardiography (TEE) demonstrated a severe MR from the middle scallops of both mitral leaflets (A2 and P2 segments). TEE also revealed that the previously implanted mitral annuloplasty ring (MAR) was detached from the anterior mitral leaflet and shifted to the central area of mitral valve (Fig. 1, 2). The 3D examination of TEE showed a double orifice sign due to the dislocation of the mitral annular ring (Video 1, 2). The preferred type of therapy for patients with detachment of MAR is usually to perform mitral valve surgery once again. For this reason, choosing appropriate diagnosis methods and the detailed examination of the mitral valve have a crucial role. The partial detachment of MAR can not be visualized with 2D echocardiography; 3D echocardiography is more helpful for these situations. Especially in case of existence of MR in patients with MRA, a 3D-echocardiographic examination can provide more detailed information regarding the valvular structure.