A case of hemolysis after mitral valve repair: evaluation of hydrodynamic patterns by three-dimensional transesophageal echocardiography

Excerpt

A 36-year-old man underwent mitral valve repair (MVRep) for severe mitral regurgitation (MR) due to anterior mitral valve degeneration. Residual MR was trivial and the postoperative course uneventful. He was followed up as an outpatient. Despite anti-hypertensive treatment, his blood pressure remained high (140–160/80–90 mmHg). Eighteen months after MVRep, his lactate dehydrogenase level gradually increased (800–1200 U/L), mild anemia progressed (Hb 10.0–12.0 g/dL), and crushed red blood cells were detected on a peripheral blood smear. The patient was diagnosed with hemolytic anemia. Slight systolic murmur was heard upon auscultation. Transthoracic echocardiography was performed. Though acceleration flow around the lateral posterior leaflet was seen on color Doppler imaging, a definitive MR jet was not visible (Fig. 1a–c; Vid. 1). Transesophageal echocardiography (TEE) was performed, revealing a prolapsed lateral anterior leaflet. Though a regurgitation orifice was confirmed on two-dimensional imaging (Fig. 1d), the MR jet was not detected on color Doppler imaging (Fig. 1f). Continuous Doppler imaging showed the approximate MR acceleration velocity (Fig. 1e). Three-dimensional (3D) imaging showed an artificial ring sutured around the mitral annulus (Fig. 1g; Vid. 2). 3D color Doppler imaging revealed the MR jet blowing backward, colliding with the posterior of the artificial ring, turning medially, and then rotating counterclockwise along the artificial ring around the mitral annulus (Fig. 1h–j; Vid. 3). He was followed up conservatively by adding an iron agent and βblocker treatment. The anemia has improved.

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