DOI: 10.1111/j.1540-8175.2011.01567.x C  2011, Wiley Periodicals, Inc. Extrinsic Mechanism Obstructing the Opening of a Prosthetic Mitral Valve: An Unusual Case of Suture Entrapment Mehmet Ozkan, M.D., F.E.S.C., ∗ Mehmet Ali Astarcioglu, M.D., ∗ Suleyman Karakoyun, M.D., ∗ and Mehmet Balkanay, M.D.† ∗ Department of Cardiology and †Department of Cardiovascular Surgery, Kartal Kosuyolu Heart Training and Research Hospital, Istanbul, Turkey Obstruction to a prosthetic cardiac valve is a well-recognized complication of cardiac valve replace- ment. Malfunction of the mobile component of a prosthetic valve to open or close correctly may occur in consequence of intrinsic or extrinsic causes (thrombus, vegetation, entrapment of left ven- tricular myocardium, suture entanglement, and pannus formation) that may result prosthetic valve stenosis and/or insufficiency. In the case we report a 48-year-old female with valve dysfunction oc- curred early after surgery, as one valve leaflet was only able to partially open due to suture entrapment. (Echocardiography 2012;29:E28-E29) Key words: suture entrapment, transesophageal echocardiography, mitral valve replacement, prosthetic valve dysfunction A 48-year-old woman underwent mitral valve replacement with a size of 29 mm St. Jude 6 months earlier for severe mitral stenosis and regurgitation. The patient was admitted to our hospital for progressive shortness of breath for 5 months, soon after operation. Atrial fibrillation was present on resting electrocardiography. Transthoracic echocardiography demon- strated normal left ventricular size and preserved systolic function, with an ejection fraction of 58%. However, severely restricted motion in one of the prosthetic mitral leaflet with a mean pressure gradient of 9 mmHg and mitral valve area of 1.5 cm 2 was identified. Two-dimensional (2D) and real time three-dimensional (3D) transesophageal echocardiography clearly demonstrated the restriction of one of the leaflets only during diastole. There was no evidence consistent with a thrombus or a vegetation (Fig. 1, movie clips 1 and 2). Fluoroscopy was performed, confirming the echocardiographic findings obtained by transesophageal examina- tion. On the basis of the acute presentation and echocardiographic findings, the presumptive diagnosis was pannus formation. However, the earlier duration was considered to be unlikely for formation of pannus. Because of the patient’s Disclosures: None. Address for correspondence and reprint requests: Mehmet Ali Astarcioglu, M.D., Department of Cardiology, Kartal Kos ¸uyolu Heart Training and Research Hospital, Denizer Caddesi Cevi- zli Kavs ¸a˘ gı, No. 2 Cevizli/Kartal, Istanbul 34846, Turkey. Fax: +90-216-459-63-21; E-mail: maliastarcioglu@hotmail.com progressively worsening hemodynamic status, the patient was referred to surgery with the diagnosis of dysfunction of mechanical mitral prosthetic valve. At reoperation, neither of pannus ingrowth and thrombus around the mitral valve were seen. Severe prosthetic mitral valve obstruction was created by entanglement of suture across the middle axis of the prosthesis on its ventricu- lar surface (Fig. 2). The entangled suture pre- vented the tilting disc occluder from falling into the left ventricular cavity during diastole. The suture was cut so that the occluder was kept away from the suture. The surgery was success- ful without any complications, and intraoperative transesophageal echocardiography showed good movement of the prosthetic mitral valve. The pa- tient was extubated a few hours after surgery and transferred to the general ward next day. She was discharged without any complications on post- operative day 6. On discharge echocardiography, normal function of the prosthetic mitral valve with a mean gradient of 3 mmHg was shown. At 1, 3, and 12th months follow-up, an echocardiogram showed no valve dysfunction. Discussion: Obstruction to a prosthetic cardiac valve is a well-recognized complication of cardiac valve replacement. Failure of the mobile component of a prosthetic valve to open or close properly may occur as a result of thrombus 1 formation, disc or ball variance, vegetation, 2 pannus formation E28