MP29. Malignant Uni/Bileaflet Mitral Valve Prolapse Syndrome Requiring Post-Cardiotomy Extracorporeal Membrane Oxygenator Therapy Following Mitral Repair
Penn State Health Milton S. Hershey Medical Center
HERSHEY, PA
United States - Contact Me
Dr Balakrishnan Mahesh, MD, PhD, is an Attending Cardiac and Transplant Surgeon at the Penn State Milton S Hershey Medical Center and an Associate Professor of Surgery at Penn State University. He is a fellowship-trained cardiothoracic surgeon who specializes in all major heart surgery including total arterial coronary bypass grafting; mitral valve repair; tricuspid valve repair; aortic root replacement surgery; minimally invasive aortic and mitral valve surgery; surgery for atrial fibrillation; redo cardiac surgery; heart and lung transplantation, and implantation of ventricular assist devices.
He has extensive experience and expertise in use of the Transmedics™ Organ Care system for heart procurement and transport, a continuous warm blood perfusion system that particularly facilitates use of ‘Donor Circulatory Death’ hearts, and extends the use of marginal hearts for organ transplantation.
As the Director of Heart transplant and Mechanical Circulatory Support at Penn State Hershey Medical Center, he excels in performing conventional cardiac surgery on patients with failing hearts, by supporting them with a gamut of short-term and long-term ventricular assist devices.
He has amalgamated best practices across both sides of the Atlantic in that prior to this appointment in the USA, he was an Attending Cardiac and Transplant Surgeon at Harefield Hospital, London, UK, senior clinical lecturer at Imperial College London and the University of Glasgow, and surgical tutor with the Royal College of Surgeons, London. He received a Clinical Excellence Award with the National Health Service in the UK.
He has published extensively and presently enjoys research in antibody-mediated rejection following heart transplantation, and development of newer left ventricular assist devices.
Description
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