MP55. Right Mini-Thoracotomy Approach for Prosthetic Mitral Valve Perivalvular Leakage Repair in a Patient with Three Previous Open Heart Surgery Procedures
Presented During: Moderated E-Posters
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Chief, Department of Cardiovascular Surgery, National Hospital Organization, Osaka National Hospital, Osaka, Japan
Thursday, May 4, 2023: 6:30 PM - Saturday, May 6, 2023: 2:29 AM
New York Hilton Midtown
Room: Grand Ballroom Foyer
Description
[Objective] With the increasing popularity of minimally invasive cardiac surgery (MICS), its indications are expanding to include not only isolated mitral valve repair but all types of mitral valve disease cases. MICS approach for patients with a history of open heart surgery is routinely used at our institution. Herein, we present a case of perivalvular leakage that developed after aortic root replacement and mitral valve replacement (MVR) performed for a patient with a history of three open heart surgery procedures.
[Case video presentation] A 76-year-old man who underwent MVR and root replacement (Freestyle valve) for infective endocarditis 20 years prior, re-MVR (mechanical valve) for a prosthetic valve infection 19 years prior, and redo Bentall surgery (mechanical valve) due to aortic root prosthesis infection 17 years prior came to our department complaining of worsening anemia and dyspnea on effort. Transesophageal echocardiography revealed severe perivalvular regurgitation on the lateral side of the mitral mechanical valve. Because of a high LDH level ( 1072 IU/L), anemia (Hb: 7.2 g/dl), and worsening dyspnea, redo surgery was considered. Based on a history of multiple midline incisions and requirement of a surgical procedure for the aortic root to reach the mitral valve with a redo sternotomy approach, a right 4th intercostal MICS approach with use of a thoracoscope was chosen. A cardiopulmonary bypass was established via the right femoral artery and vein, and the adhesion in the thoracic cavity was dissected. Although the left atrial incision line was easy to approach, it was considered that dissection around the aortic root prosthesis would be too severe for aortic cross-clamping, thus we decided to perform an on-pump beating approach without cardiac arrest. The left atrium was opened under rapid pacing and a suction tube inserted into the left ventricle. After confirming a large regurgitation site around the valve on the lateral side, the perivalvular leakage site was directly sutured with 2-0 ethibond sutures with felt used in the area with strong tissue and a bovine pericardium patch in the fragile area of the annulus. No obvious perivalvular leakage was observed.
[Conclusion] MICS approach for mitral valve surgery in a patient with a history of open heart surgery can minimize adhesion dissection and secure the operative site after aortic root replacement, and is considered to be a useful option for redo mitral valve surgery case
[Case video presentation] A 76-year-old man who underwent MVR and root replacement (Freestyle valve) for infective endocarditis 20 years prior, re-MVR (mechanical valve) for a prosthetic valve infection 19 years prior, and redo Bentall surgery (mechanical valve) due to aortic root prosthesis infection 17 years prior came to our department complaining of worsening anemia and dyspnea on effort. Transesophageal echocardiography revealed severe perivalvular regurgitation on the lateral side of the mitral mechanical valve. Because of a high LDH level ( 1072 IU/L), anemia (Hb: 7.2 g/dl), and worsening dyspnea, redo surgery was considered. Based on a history of multiple midline incisions and requirement of a surgical procedure for the aortic root to reach the mitral valve with a redo sternotomy approach, a right 4th intercostal MICS approach with use of a thoracoscope was chosen. A cardiopulmonary bypass was established via the right femoral artery and vein, and the adhesion in the thoracic cavity was dissected. Although the left atrial incision line was easy to approach, it was considered that dissection around the aortic root prosthesis would be too severe for aortic cross-clamping, thus we decided to perform an on-pump beating approach without cardiac arrest. The left atrium was opened under rapid pacing and a suction tube inserted into the left ventricle. After confirming a large regurgitation site around the valve on the lateral side, the perivalvular leakage site was directly sutured with 2-0 ethibond sutures with felt used in the area with strong tissue and a bovine pericardium patch in the fragile area of the annulus. No obvious perivalvular leakage was observed.
[Conclusion] MICS approach for mitral valve surgery in a patient with a history of open heart surgery can minimize adhesion dissection and secure the operative site after aortic root replacement, and is considered to be a useful option for redo mitral valve surgery case