A 70-year-old woman presented with long-standing mitral regurgitation, aortic regurgitation, and paroxysmal atrial fibrillation. She demonstrated increasing left atrial and left ventricular enlargement, which prompted surgical referral. Despite prominent mitral annular calcification, the surgeon was able to successfully repair her mitral valve, using plication of the middle scallop of the posterior leaflet, an Alfieri stitch, and placement of a 35-mm annuloplasty ring. She also underwent replacement of the aortic valve with a #23 Carpentier-Edwards bovine pericardial heterograft, isolation of the pulmonary veins, and ligation of the left atrial appendage (Figs. 11.2, 11.3, 11.4, and 11.5).

A 43-year-old woman in previously excellent health presented with a cerebrovascular accident due to middle cerebral artery occlusion. She was emergently treated with fibrinolysis and achieved full recovery. She subsequently was found to have severe mitral stenosis, despite an absence of previous symptoms. The transvalvular peak gradient was 23 mmHg and the mean gradient was 14 mmHg, with moderate (2–3+) mitral regurgitation. She was anticoagulated and then referred for mitral balloon valvuloplasty, which was performed via a trans-septal puncture. After the procedure, the gradients were reduced to 16 and 9 mmHg, with only mild (1+) residual mitral regurgitation, and the estimated mitral valve area (by pressure half time) was 1.9 cm² (Figs. 11.6, 11.7, 11.8, 11.9, 11.10, 11.11, 11.12, and 11.13).

A 62-year-old woman with end-stage renal failure on hemodialysis presented with a severe paravalvular mitral valve leak, severe tricuspid regurgitation, and moderate aortic stenosis on a background history of previous bioprosthetic mitral valve replacement and coronary artery bypass graft surgery 3 years earlier. She underwent a mitral valve replacement with an On-X mechanical valve (#33), a tricuspid valve repair with a Carpentier ring (#30), an aortic valve replacement with a Trifecta bioprosthesis (#23), and coronary artery bypass graft surgery.

Preoperative echocardiography demonstrated a paravalvular leak originating at the anterolateral aspect of the mitral annulus. The eccentric, regurgitant jet hugged the wall of the left atrium and was difficult to quantitate, but visually it appeared severe. Transvalvular peak and mean gradients of 17 and 9 mmHg were noted (Figs. 11.14, 11.15, and 11.16).

A 51-year-old woman with a past history of mitral valve replacements 20 and 27 years previously now presents with hemolytic anemia, atrial fibrillation, and a small (5 mm) mitral paravalvular leak with severe tricuspid regurgitation. She has symptoms of right heart failure with evidence of fluid overload. She has known biventricular dysfunction, with implantation of an implantable cardiac defibrillator.

Echocardiography demonstrated biventricular enlargement. The St. Jude mechanical prosthetic mitral valve replacement was associated with a moderate (2–3+), posterolaterally directed paravalvular leak, which originated adjacent to the lateral aspect of the valve near the left atrial appendage ostium, although the valve itself remained well seated. There was severe (4+) tricuspid regurgitation related to annular dilatation.

She successfully underwent her third cardiac surgery involving mitral valve replacement with an On-X mechanical valve (#33) and a tricuspid valve repair with a Carpentier classic annuloplasty ring (#30) (Figs. 11.17, 11.18, 11.19, and 11.20).

A 67-year-old woman presented with mild exertional dyspnea and mild hemolytic anemia. Her background history included myxomatous mitral valve disease, for which she underwent mitral valve replacement over 10 years ago, followed by replacement with a porcine valve and tricuspid repair 3 years ago.

Transthoracic and transesophageal echocardiograms were remarkable for a moderate (2+), anterolateral mitral paravalvular leak, although the mitral valve prosthesis appeared otherwise well-seated. The vena contracta measured 0.1 cm². Otherwise, there was only trivial valvular regurgitation, with no restriction of leaflet excursion. The peak and mean gradients were 22 and 6 mmHg. The tricuspid valve repair appeared intact, with only trivial regurgitation and a mean gradient of 4 mmHg (Figs. 11.21, 11.22, 11.23, and 11.24).

Given her lack of symptoms and only mild anemia, she will have ongoing follow-up with serial echocardiography every 6–12 months, or sooner if her symptoms worsen.

A 77-year-old woman was referred with a history of coronary artery bypass graft surgery and bioprosthetic aortic (#21) and mitral (#25) valve replacements for aortic stenosis and mitral regurgitation 2 months earlier. The surgery had been complicated by severe mitral annular calcification and bleeding from the AV groove and posterior ventricle, which required a pericardial patch. She now reported worsening symptoms of heart failure, and echocardiography demonstrated partial dehiscence of the mitral valve with a resultant severe, posterior paravalvular leak (measuring 1.0 cm in maximal diameter), which was in direct communication with a large (5.0 × 4.1 cm) pseudoaneurysm adjacent to the left atrium, which obstructed pulmonary venous drainage (Figs. 11.25, 11.26, 11.27, and 11.28). The aortic valve replacement was well seated, with only trivial regurgitation. Reoperation was performed involving removal of the old prosthesis, unroofing and repair of the pseudoaneurysm, and replacement of the mitral valve with a Biocor #29 prosthesis.