Malignant uni/bileaflet mitral valve prolapse syndrome requiring post-cardiotomy extracorporeal membrane oxygenator therapy following mitral repair

MP029 

Abstract Submission 

BALAKRISHNAN MAHESH (1), Annick Haouzi (2), Behzad Soleimani (3)

(1) N/A, United Kingdom, (2) Cleveland Clinic Foundation, Cleveland, OH, (3) N/A, N/A

♦Balakrishnan Mahesh    -  Contact Me
N/A

Annick HAOUZI    -  Contact Me
Cleveland Clinic Foundation

Behzad Soleimani    -  Contact Me
N/A

♦Balakrishnan Mahesh    -  Contact Me
N/A

Objective

Post-cardiotomy Cardiogenic shock [PCCS] following mitral repair for severe mitral regurgitation [MR] is an infrequent complication. Often taking the surgeon by surprise, due to combination of over-estimation of LVEF due to severe MR, and myocardial stunning, we report 3 interesting cases recovered successfully with extracorporeal membrane oxygenator therapy [ECMO] for PCCS, following difficult repair

Methods

Between January 2022 and 2023, 3 patients underwent complex mitral repair, using standard antegrade/retrograde Buckberg cardioplegia.

Results

Patient 1: severe MR due to bileaflet prolapse & posterior commissure [PC] involvement, and interestingly, some restriction in initial portion of P2 due to LAD infarct and LV dilatation, & moderate aortic stenosis. He was diagnosed with Ischemic cardiomyopathy with LVEF 28% 6 years ago, which improved with biventricular pacing and medical therapy to 40%. He underwent bileaflet repair with chordal transfer to A2, neochords to A2, A3, P2, P3, cleft closure P1/2, PC advancement, 40mm complete mitral ring, aortic valve replacement, biatrial maze, & LIMA to LAD

Patient 2: severe MR due to acute posterior leaflet prolapse from multiple ruptured primary cords to P2/3 due to chest trauma, severe pulmonary hypertension, severe functional tricuspid regurgitation [FTR] with dilated RV, and atrial fibrillation [AF]. He presented with ascites and congestive failure, requiring pre-optimization. He underwent mitral repair with neochords to P2, P3, cleft closure P2/3, PC advancement, 36 mm complete mitral ring, a 32mm tricuspid partial ring, & biatrial maze

Patient 3: severe MR due to prolapse of A2, A3, P2, P3, & PC involvement, AF, biventricular dysfunction, severe FTR. She underwent mitral repair with Neochords to A2, A3, P2, 40mm complete mitral ring, 30mm partial tricuspid ring, & biatrial maze.

All 3 patients required perioperative ECMO support, and are alive and well currently

Conclusions

These cases highlight the difficulty in estimating preoperative LV dysfunction in patients with complex mitral pathology. Preoperative right heart catheter studies remain paramount for prognosis and risk stratification in these patients, as LVEF grossly over-estimated function and is therefore inadequate [Table-1]. ECMO provides a very elegant way of managing PCCS in these patients, allowing recovery of biventricular function without end-organ dysfunction seen with high-inotropic support alone

Malignant Bileaflet Mitral Valve Prolapse Syndrome