Emergent/Salvage Minimally Invasive Mitral Valve Replacement

The Case

The authors present the case of a 47-year-old man who presented to the emergency department with a one-week history of chest pain. At presentation, he was hypotensive and required mechanical ventilation and an emergent trip to the catheterization lab, where he was found to have an occlusion of the right coronary artery. A PCI/stenting of the RCA was performed successfully on clopidogrel and heparin. An Impella CP device was inserted via the left femoral artery. Presentation CXR showed severe bilateral pulmonary edema and given hypoxia and profound shock supported with over-max dose pressors and inotropes (epinephrine, norepinephrine and dopamine), the patient was cannulated percutaneously peripherally in the ICU for VA-ECMO. Transesophageal echocardiogram showed severe complex mitral regurgitation with bileaflet flail, suggestive of a ruptured papillary muscle tip flailing with the leaflet. 

The Outcome

The patient was separated from cardiopulmonary bypass successfully but given hypoxia, the cannulas were reconnected to a new VA-ECMO circuit, and the patient transferred to the intensive care unit. After a day of continuous hemodialysis and volume removal, his oxygenation improved so he was decannulated in the intensive care unit with a groin cutdown under local anesthesia and sedation. He was extubated on postoperative day four, subsequently had full recovery, and was discharged to the rehabilitation facility on postoperative day 28 with an LVEF of 40%. 

Emergent minimally invasive mitral valve surgery

This case is meant to illustrate an experience of performing minimally invasive mitral valve surgery emergently or salvage situations successfully. Not shown here, but equally treated, have been patients supported on isolated Impella and isolated VA-ECMO. Emergent mitral valve replacement has been reported in the literature. Nguyen et al. (1) reported the first and only minimally invasive emergent mitral valve repair on a puerperal woman. LaPar et al. (2) demonstrated that urgent or emergent mitral valve operations made up 384/1477 mitral valve operations performed in the state of Virginia from 2003-2008. Minimally invasive mitral valve surgery in emergent situations can be performed at high volume minimally invasive centers, from ischemic catastrophes to isolated mitral/tricuspid infectious endocarditis. The benefits of avoiding a sternotomy in sepsis are important. From a technical aspect, one must account for the presence of ventricular assist devices traversing the aorta while applying the crossclamp. For this reason, using a crossclamp with soft inserts is superior so as to prevent damage to the aorta which can conceivably happen with all-metal clamps. Another consideration is verifying that the intraventricular portion of the temporary LVAD is free of the valve sutures when seating the valve. For this purpose, liberal use of the scope and/or a long dental mirror is important. Finally, consideration to converting a form of extracorporeal support to another is reasonable, for example Impella to VA-ECMO. Right minithoracotomy techniques do not require special setup, personnel, or equipment outside of a regular operating day and can be performed at a moment's notice. 

References

1. Nguyen S, Umana-Pizano JB, Donepudi R, Dhoble A, Nguyen TC. Minimally invasive mitral valve repair for acute papillary muscle rupture during pregnancy. Ann Thorac Surg. 2019 Feb;107(2):e93-e95.
2. LaPar DJ, Hennessy S, Fonner E, Kern JA, Kron IL, Ailawadi G. Does urgent or emergent status influence choice in mitral valve operations? An analysis of outcomes from the Virginia Cardiac Surgery Quality Initiative. Ann Thorac Surg. 2010 July;90(1):153-160.

Disclosure

Mario Castillo-Sang is an Edwards Lifescience and Cryolife paid advisor.

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