A 13 × 20 mm mobile vegetation (image A) resembling a golf ball, and causing dynamic left ventricular outflow tract (LVOT) obstruction, was found to be attached to the anterior mitral valve leaflet (AMVL) on the ventricular side by transesophageal echocardiography in the midesophageal long-axis view, sparing the posterior mitral valve leaflet (PMVL). Most vegetations on the mitral valve attach to the atrial (low flow, left atrium [LA]) side of the leaflet, but on rare occasions are on the ventricular (high flow) side.1 Vegetation location, regurgitation mechanism, and severity of the LVOT obstruction were assessed by color flow Doppler. The presence of the mass on the leaflet tip prevented leaflet coaptation, resulting in central mitral regurgitation (MR) in systole.2 There was flow convergence within the left ventricle (LV) proximal to the mass as well as flow acceleration that began at the mass proximal to the aortic valve, causing a dynamic LVOT obstruction (image B). This large (greater than 10 mm) mass posed a high risk for systemic embolization.3
Hemodynamic management can be challenging in the presence of MR, low systemic vascular resistance in the presence of sepsis, general anesthesia, and dynamic LVOT obstruction. Ensuring adequate coronary and systemic perfusion by optimizing preload and maintaining sinus rhythm with a moderate rate should be the goal. Continuous intraoperative transesophageal echocardiography confirms vegetation size and location; defines the degree of valve involvement and damage to surrounding tissue; facilitates hemodynamic monitoring; and alerts the anesthesiologist to systemic embolization.2
The authors declare no competing interests.