Unilateral Pulmonary Edema Due to Leaflet Fracture of a Duromedics Edwards Bileaflet Mitral Valve

Unilateral focal pulmonary edema can be a manifestation of eccentric mitral valve insufficiency.1Ogunbayo G.O. Thambiaiyah S. Ojo A.O. et al.‘Atypical pneumonia’: Acute mitral regurgitation presenting with unilateral infiltrate.Am J Med. 2015; 128: e5-e6Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar A patient presented with unilateral lobar consolidation due to prosthetic mitral valve insufficiency, which initially was not diagnosed by transthoracic echocardiography (TTE), but then was detected by transesophageal echocardiography (TEE). A 46-year-old man, 26 years post-mitral valve replacement with an Edwards Duromedics mechanical valve for infective endocarditis, was transferred to the intensive care unit with sudden-onset nausea and severe dyspnea. Positive findings of the physical examination included a respiratory rate of 25/minute, heart rate of 138 beats/minute, and a systolic ejection murmur loudest at the second intercostal space at the right sternal border. Laboratory tests showed white blood cell count 22,000/µL, procalcitonin>10 ng/mL, and brain natriuretic peptide 73.7 pg/mL. Focal lobar consolidation was seen in the right lower lung on chest x-ray. TTE showed normal ejection fraction with no valve regurgitation. Thoracic computed tomography showed alveolar consolidation with air bronchogram, surrounded by ground glass opacification in the right lower lobe. Due to progressive dyspnea, he was intubated and placed on mechanical ventilation and treated with antibiotics for 9 days for presumed lobar pneumonia. After failing to improve despite adequate treatment for pneumonia, the decision was made to perform TEE, which revealed severe mitral regurgitation in the midesophageal aortic valve long-axis view, presumably due to malfunction of the prosthetic valve. Emergency mitral valve replacement was performed. Intraoperatively, it was noted that the posterior leaflet of the bileaflet prosthesis was missing. Whole-body computed tomography scan was performed, and the valve fragment was in the right common iliac artery. The valve fragment was removed 10 weeks later and had a transverse fracture (Fig 1). The Edwards Duromedics mechanical valve was introduced into clinical use in 1982 and withdrawn from the market in 19882Podesser B.K. Khuenl-Brady G. Eigenbauer E. et al.Long-term results of heart valve replacement with the Edwards Duromedics bileaflet prosthesis: A prospective ten-year clinical follow-up.J Thorac Cardiovasc Surg. 1998; 115: 1121-1129Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar due to several case reports of valve leaflet fracture after implantation.3Baumgartner F.J. Munro A.I. Jamieson W.R. Fracture embolization of a Duromedics mitral prosthesis.Tex Heart Inst J. 1997; 24: 122-124PubMed Google Scholar In the present patient, the valve leaflet was fractured and escaped 26 years after placement. Unilateral pulmonary edema is a well-known manifestation of eccentric mitral valve insufficiency.1Ogunbayo G.O. Thambiaiyah S. Ojo A.O. et al.‘Atypical pneumonia’: Acute mitral regurgitation presenting with unilateral infiltrate.Am J Med. 2015; 128: e5-e6Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar In this patient, severe mitral regurgitation was caused by the escaped mechanical valve leaflet, which initially was not seen on TTE and then was detected by TEE.4Roach J.M. Stajduhar K.C. Torrington K.G. Right upper lobe pulmonary edema caused by acute mitral regurgitation. Diagnosis by transesophageal echocardiography.Chest. 1993; 103: 1286-1288Abstract Full Text Full Text PDF PubMed Scopus (52) Google Scholar It usually is difficult to detect mitral regurgitation by color-flow imaging because of shielding of the left atrium by the mitral prosthesis. TEE is an important diagnostic option in the evaluation of unilateral focal pulmonary consolidation, particularly with a history of mitral valve replacement.