A child's post-op heart failure was incorrectly called irreversible: When catastrophic post-op decline may still have a fixable cause
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A sudden drop in cardiac output with shock, new pulmonary edema, a new murmur, hemolysis, or a sharp rise in lactate with increasing requirement for inotropic support requires an immediate evaluation of the result of the valve surgery.
—I. Oral Hastaoğlu, MD
According to a recent lawsuit, a 13-year-old girl underwent valve replacement at Oregon Health & Science University and became gravely ill before being transferred to Seattle Children’s Hospital.[]
Related: Doctors told teen she was dying, then a second facility found an upside-down heart valve: Inside this $17M malpractice suitThe complaint alleges that surgeons there discovered the valve had been implanted upside down and that her heart function improved after revision surgery.
Although the litigation is still ongoing, the case forces physicians to ask: When severe decline follows valve surgery, could a potentially correctable mechanical issue be contributing to the patient’s deterioration?
So, how do valve-related issues such as prosthetic valve obstruction, malposition, or paravalvular leak usually present in the OR or ICU?
“These complications are most commonly identified in the operating room during routine TEE [transesophageal echocardiogram] assessment immediately after separation from cardiopulmonary bypass. Findings may include elevated valve gradients, abnormal leaflet motion, paravalvular regurgitation, ventricular dysfunction, or unexplained hemodynamic instability. Early detection allows prompt correction before the patient leaves the operating room,” says cardiothoracic surgeon Abdul Elnaggar, MD, at Penn State Heart and Vascular Institute.
TEE before the patient leaves the OR
Intraoperative TEE exists for this moment. The 2020 American Society of Echocardiography guideline states that intraoperative TEE is a standard tool across cardiac surgery, from surgical coronary revascularization to complex valve repair and transplant.[] The same guideline stresses procedure-specific imaging and clear communication with the surgical team.
After separation from cardiopulmonary bypass, intraoperative TEE should assess prosthetic valve function, ventricular performance, regional wall-motion abnormalities, residual valvular lesions, LV outflow tract obstruction, pericardial effusion or tamponade, intracardiac air, and other residual structural abnormalities that may require immediate surgical correction.
Residual lesions
Residual lesions are problems left behind after cardiac surgery or new problems created by the repair.[]
Examples include prosthetic valve malposition, paravalvular leak, underestimated MR, LVOT obstruction, residual VSD or ASD, pulmonary venous obstruction, coronary compromise, aortic dissection, and tamponade.
And many of these residual lesions are fixable mechanical issues, as highlighted by I. Oral Hastaoğlu, MD, a professor of cardiovascular surgery at Erdem Health Group.
“[With regard to] malposition of a valve, severe residual regurgitation, a large paravalvular leak, obstruction of a coronary artery, LVOT obstruction, tamponade, and major air embolism, many of these problems can be corrected in the operating room, but they have to be recognized before the patient leaves the operating room,” he says.
The 2025 American Heart Association scientific statement states that intraoperative echocardiography can detect residual lesions that contribute to morbidity and mortality after repair.[]
The same statement also notes that real-time 3D TEE for complex lesions may be used to identify abnormalities with better accuracy, sensitivity, and specificity than 2D TEE without reducing exam efficiency.
Low output
A blocked or obstructed mitral prosthesis can function like severe mitral stenosis: left ventricular filling falls, left atrial pressure rises, and the patient may present with pulmonary edema, heart failure, or cardiogenic shock.[][]
“Myocardial stunning is an anticipated post-valve surgery complication with eventual resolution. When cardiac output remains low long after the early post-bypass period despite good preload and stable rhythm, there is something else at work. Regional wall motion abnormalities that are new, not present prior to bypass, indicate a structural or ischemic cause that must be identified, not observed,” says Jason Schroder, DO, a board-certified anesthesiologist.
Prosthesis thrombosis
Case reports of mechanical mitral prosthesis thrombosis describe patients presenting in cardiogenic shock, and a surgical series of mechanical valve thrombosis found that heart failure was the most common presentation, occurring in 13 of 20 patients, or 65%.[]
The European Society of Cardiology similarly describes mechanical left-heart valve thrombosis as potentially life-threatening because of severe hemodynamic dysfunction, with presentations including dyspnea and acute pulmonary edema.[]
According to Vuyisile T. Nkomo, MD, MPH, director of Mayo Clinic’s Valvular Heart Disease Clinic, “Thrombotic risk is related to the type of valve, position of the valve and adequacy of anticoagulation.”[]
Related: A boy's heart stopped for 19 hours and then it started againWhat every clinician should remember
Most physicians will not be in the cardiac OR. Many will see the patient afterward, in the ICU, clinic, rehab, or primary care.
“It is easy to confuse an expected postoperative course of severe inflammation with cardiac stunning, but a sudden drop in cardiac output with shock, new pulmonary edema, a new murmur, hemolysis, or a sharp rise in lactate with increasing requirement for inotropic support requires an immediate evaluation of the result of the valve surgery. It is a mechanical problem that loses value with each passing hour. The surgeon and echo team should be called quickly,” I. Oral Hastaoğlu says.