New-onset Mitral Valve Regurgitation Postbilateral Lung Transplantation – A Case Report

Dear Editor, My purpose in writing this letter is to shed light on an uncommon cardiac complication that can occur following a bilateral lung transplant, known as “New onset mitral valve regurgitation (MR) postbilateral lung transplantation.” I strongly believe that this complication holds great clinical significance within the field of organ transplantation. There have been no previous reports of this complication from the Indian subcontinent. This particular case exemplifies the causes and treatment of this rarely documented, life-threatening valvular complication that can develop during the posttransplant period. Lung transplantation has greatly benefited individuals with advanced lung diseases, enhancing both their life expectancy and quality of life. Posttransplant patients may experience a variety of infectious and noninfectious complications that can undermine the benefit mentioned above. As part of the pretransplant workup, a cardiac evaluation is performed in every case to exclude and optimize any notable cardiac issues. However, new cardiac complications can occur during the posttransplant period. In the literature, dysrhythmias are often mentioned as occurring after a transplant.[1] However, it is worth noting that there is limited data available on valvular complications, especially when it comes to MR. Herein, we present the case of a 57-year-old male, with severe MR which occurred de novo postbilateral lung transplant, highlighting its cause and management. A 57-year-old male with a diagnosis of idiopathic pulmonary fibrosis type of interstitial lung disease complicated by respiratory failure and pulmonary hypertension was considered for bilateral lung transplant. The pretransplant right heart catheterization study revealed systolic pulmonary artery pressures of 55 mmHg, diastolic pressures of 16 mmHg, and a transpulmonary gradient of 26 mmHg. The pretransplant transthoracic echocardiogram showed enlargement of the right atrium and right ventricle, along with tricuspid regurgitation. The left ventricular ejection fraction was within normal range. With a graft ischemic time of 450 min, he underwent a successful double lung transplant. Intraoperative transesophageal echocardiography showed preserved left ventricular function and no evidence of MR. The patient had ventilator-associated pneumonia postoperatively and was tracheostomized in view of difficult weaning. The patient made uneventful recovery and was decannulated on day 28 posttransplant. The patient had an episode of severe desaturation requiring mechanical ventilation on day 33 posttransplant. Frothy serosanguinous fluid denoting pulmonary edema was noted in tracheostomy tube secretions. Comparison chest radiograph at time of worsening with immediate posttransplant one shows it to be consistent with pulmonary edema [Figure 1a and b]. Transthoracic echocardiogram revealed severe MR with centrally oriented regurgitation with normal valvular anatomy [Figure 2]. No evidence of resting wall motion abnormality, tricuspid regurgitation, or endocarditis were found. Coronary angiogram ruled out acute coronary event. The patient was placed on venoarterial extracorporeal membrane oxygenation support as a bridge with a definite plan to proceed with mitral valve replacement. However, another episode of nosocomial pneumonia with disseminated intravascular coagulation led to postponement of the procedure. The patient had refractory shock on day 40 postlung transplant and eventually succumbed.Figure 1: (a) Chest radiograph anteroposterior view postlung transplant day 1 showing clear lung fields, (b) Chest radiograph anteroposterior view postlung transplant day 33 showing bilateral fluffy opacities involving the bilateral lung fieldsFigure 2: Four-chamber transthoracic echocardiogram showing moderate-to-severe regurgitation (blue jet) across the mitral valve (white asterisk). RA: Right atrium, RV: Right ventricle, LA: Left atrium, LV: Left ventricleIt was an unusual occurrence of a severe noninfectious and nonischemic MR complicating the recovery of a patient who had undergone a double lung transplant. To the best of our understanding, there have been no similar cases reported from the Indian subcontinent. The mechanism underlying MR in this patient may be related to subacute anatomic changes in the right and left ventricular chambers. The reduction in systolic pulmonary pressure that occurred after the lung transplant was associated with a reduction in the size of the right ventricle, leading to large left ventricular cavity and change in geometry of mitral valve annulus. These anatomic changes lead to lack of coaptation between the anterior and posterior leaflets leading to MR. Pulmonary edema postlung transplantation can occur from diverse causes. Spectrum of culprit etiology ranges from infectious causes such as infective endocarditis and allograft infection to noninfectious causes such as primary graft dysfunction, acute cellular rejection, and pulmonary vein stenosis.[2] Ischemic MR because of coronary artery disease also needs to be ruled out before attributing pulmonary edema to be due to functional MR. Literature regarding the management of MR in this setting is limited to case reports. Initial trial of conservative management with arterial vasodilators like nitroprusside along with diuretics has been explained with resort to more invasive mitral valve repair in case the above management fails.[3] Nevertheless, surgical repair is challenging in this scenario on an account of already compromised patient. Our case highlights a rare but equally morbid valvular complication after lung transplantation. This complication may be related to changes in ventricular geometry, but other conventional causes of MR also need to be ruled out. Management of severe MR can follow the same management approach as in the nontransplant patient, with the expectation of similar good results. Declaration of patient consent The authors certify that patient consent has been taken for participation in the study and for publication of clinical details and images. Patients understand that the names and initials would not be published, and all standard protocols will be followed to conceal their identity. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.