Intraoperative Discovery of Bioprosthetic Mitral Valve Thrombus on TEE During HeartMate 3 Implantation: Implications for Anesthetic Management and Surgical Planning

We present the case of a 73-year-old female with chemotherapy-induced cardiomyopathy, severe mitral regurgitation status post bioprosthetic mitral valve (MV) replacement one year prior, and atrial fibrillation, admitted for evaluation for left ventricular assist device (LVAD) implantation. While her preoperative transthoracic echocardiogram (TTE) did not reveal a discrete mass, it showed a mean mitral gradient of 7 mmHg; intraoperative transesophageal echocardiography (TEE) identified a 2 cm × 1.2 cm thrombus on the bioprosthetic MV. Given these findings, the surgical team decided to replace the mitral valve concurrently with LVAD implantation. Although this approach is not routine, the goal was to improve her quality of life and reduce postoperative complications. Post-procedure TEE showed an improved MV mean gradient of 3 mmHg with no evidence of paravalvular leak. The patient was subsequently discharged home in stable condition without any thromboembolic events. This case highlights the challenges of managing complex valvular pathology in patients undergoing LVAD placement.