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JAMA Cardiology Clinical Challenge
December 2016

Pulmonary Edema Occurring 15 Years After Mitral Valve Replacement

Author Affiliations
  • 1Section of Cardiology, University of Chicago Hospital, Chicago, Illinois
  • 2Section of Cardiothoracic Surgery, University of Chicago Hospital, Chicago, Illinois
JAMA Cardiol. 2016;1(9):1073-1074. doi:10.1001/jamacardio.2016.2880

A 77-year-old man with a history of mitral valve replacement, previous coronary artery bypass grafting, atrial fibrillation, and heart failure presented to our clinic for evaluation of worsening exertional dyspnea. In 1998, he underwent mitral valve replacement with a St Jude mechanical prosthesis for severe mitral regurgitation owing to a flail leaflet, with 2-vessel coronary artery bypass grafting. He reported compliance with warfarin therapy for many years.

One year ago, he noted the onset of exertional dyspnea that culminated in multiple recurrent admissions for decompensated heart failure requiring intravenous diuretics. While hospitalized, he underwent a cardiac catheterization that demonstrated patent bypass grafts but a profoundly low cardiac output and elevated pulmonary capillary wedge pressure. A transthoracic echocardiogram was performed that suggested the presence of a significantly elevated gradient across his mitral prosthesis. A plain radiography of the chest demonstrated a mechanical prosthesis (Figure 1A). A transesophageal echocardiogram was then performed that demonstrated complete immobilization of 1 mechanical leaflet and impaired excursion of the other leaflet (Figure 1B), with subsequent severe mitral stenosis (Figure 1C) at a baseline heart rate of 82 bpm. He developed worsening hemodynamic instability and refractory pulmonary edema, and a TandemHeart left ventricular assist device was placed for cardiogenic shock.