Minimally Invasive Beating Heart Mitral Valve Replacement; A Better Option For High Risk Reoperative Mitral Patients?
K. FON Huang.
Mercy Hospital, Springfield, MO, USA.
Background: Patients presenting for reoperative mitral valve surgery can be very high risk. Challenges include re-entry sternotomy, open bypass grafts, prior valve prostheses, calcified aortas, residual coronary disease and cardiomyopathy. Cardioplegia, myocardial protection can be challenging. Transcatheter mitral valve replacement ( MVR) has limited availability and a high operative mortality (29%). Mitraclip has limited anatomic indications. In ischemic cardiomyopathy, there is a high recurrence of regurgitation (32%) in repair. Methods: A minimally invasive, right 4th interspace thoracotomy (mini) approach and warm beating heart, chordal preserving MVR can avoid these issues. Left atrium is entered when arterial waveforms are nearly flat. Anterior leaflet chords are transposed to the posterior annulus during suturing. Vents are positioned in the ventricle, through the prosthesis and inferior pulmonary vein. Two recent cases illustrate this. 78 year old man with Class 3+ CHF, occasional angina has chronic Afib, prior CABGX5 . Lateral wall grafts are occluded . Right coronary and IMA grafts are patent. LVEF is 35%, basal dilation, inferior akinesis and severe MR due to posterior tethering and anterior prolapse. He received a 31 mm porcine valve during a 136 minutes pump run (CPB) and 675 mL of cell saver only. 66 year old obese woman with a past mechanical AVR + CABGX4 presents with dyspnea from an anterior flail due to ruptured chords, right half of A2. All grafts including IMA are patent. She has a sternal dehiscence, doubled wires are broken and heavy calcium in her ascending aorta and arch. She received a bioprosthesis, 193 minutes CPB, no transfusions and 313 mL of cell saver blood. Results: Case 1 extubated, in chair early next morning. No transfusions or complications, discharged with home health on day 4. Doing well at 1 month followup. Case 2 extubated 3 hours postop. Had postop Afib, discharged on day 8 when her INR reached 2.4
Conclusions: Using a mini-warm beating heart MVR approach for high risk reoperative patients avoided technical complications and lead to a remarkable postop recovery. Further pursuit and follow up of this option is warranted and should be analyzed in comparison to other mitral valve therapies for high risk, surgically challenging patients.
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