Totally Endoscopic Minimally Invasive Mitral Valvuloplasty with Beating Heart for Treatment of Acute Myocardial Infarction Complicated with Papillary Muscle Rupture

MO007 

Case Video Submission 

Huanlei Huang (1), Zhenzhong Wang (1), XIN ZANG (2), Junfei Zhao (3)

(1) N/A, N/A, (2) N/A, Guangzhou, China, (3) Guangdong Provincial People's Hospital, Guangzhou, Guangdong

Huanlei Huang    -  Contact Me
N/A

Zhenzhong Wang    -  Contact Me
N/A

XIN ZANG    -  Contact Me
N/A

Junfei Zhao    -  Contact Me
Guangdong Provincial People's Hospital

Huanlei Huang    -  Contact Me
N/A

Objective: Papillary muscle rupture after coronary stent implantation in acute myocardial infarction is a life-threatening complication. Totally endoscopic minimally invasive mitral valvuloplasty (TEMI-MVP)with beating heart is a viable and effective option.

Case Video Summary: A male Patient(64y) was emergently transferred to our hospital with the support of IABP and ECMO, who underwent stent implantation 3 days ago for acute total occlusion of right coronary. Echocardiography showed severe mitral regurgitation with posterior leaflet flail associated with a highly mobile mass representing ruptured papillary muscle head. TEMI-MVP on beating heart was performed. Cardiopulmonary bypass(CPB) was established with previous cannulations of the femoral artery and vein of ECMO, and ECMO system maintained a self-circulation. The minimally invasive approach was adopted, thoracic cavity was flushed continuously by CO2. Excellent mitral valve exposure could be obtained through the incision of the interatrial groove with left atrial retractor. Intraoperative exploration revealed rupture of the complete posteromedial papillary muscle, and posterior leaflet prolapse. Ruptured papillary muscle heads was removed, and two groups of artificial chordae were anchored using 5-0 ePTFE suture; the posterior internal commissure was closed by continuous suture using 5-0 suture and strengthened by two pledgetted mattress sutures; finally, 28# annuloplasty full ring was implanted. Saline injection test showed good function of mitral valve, then the left atrial was closed. Left ventricular drainage tube was not removed for decompression, and the other end of the tube was connected to the cannulation of femoral vein through the chest wall via the major operating port. Postoperative transesophageal echocardiography (TEE) showed trivial regurgitation, the mean mitral valve pressure gradient was 4mmHg. CPB was weaned off smoothly, the cannulations of femoral artery and vein were reconnected to ECMO. The patient was conscious on postoperative day 2, weaned from ECMO, IABP, and ventilator on postoperative day 5, 7, 21, respectively.

Conclusions: For the patients in the early stage of coronary stent implantation for acute myocardial infarction complicated with papillary muscle rupture, beating heart technique was helpful to reduce myocardial injury. Minimally invasive mitral valve repair could improve surgery outcomes. However, pulmonary edema had adverse effect on surgical vision.

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