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@#Thoracoscopic minimally invasive technology has been used in mitral valve plasty since 1990s. Totally thoracoscopic mitral valve plasty has the advantages of small trauma, beautiful incision and rapid postoperative recovery. It is favored by more and more patients and cardiac surgeons. However, according to the reports, the proportion of totally thoracoscopic mitral valve surgery in China is still low. Mitral valve plasty via the totally thoracoscopic approach is still controversial in terms of population adaptation, perioperative complications and long-term prognosis. In addition, the technical difficulty and the long training cycle of surgeons also limit the popularization of this technology. By summarizing the existing literature, this paper analyzes the application and development of totally thoracoscopic approach in comparison with the traditional median thoracotomy mitral valve plasty.
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A 65-year-old woman was admitted to our hospital complaining of chest pain in 2012. Coronary computed tomography angiogram revealed left main coronary artery atresia (LMCAA) with congenital absence of the left main trunk, and LAD received several collaterals perfusing from the RCA. She was observed because her symptoms were transient. However, her dyspnea on effort gradually became worse in 2016. Treadmill exercise electrocardiography showed ST depression in II・III・aVF and V4-6. Also, echocardiography showed severe MR due to the prolapse of the anterior leaflet and moderate TR. We performed mitral valve plasty and tricuspid valve plasty, and coronary artery bypass grafting using the left internal thoracic artery to the left descending artery in March, 2017. The postoperative course was uneventful. She was discharged in good condition 14 days after operation. LMCAA is a rare coronary anomaly. There are only 53 published case reports, and a few surgical reports in adult cases. This is a rare adult case of surgical treatment of LMCAA.
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Heart failure is a progressive disease. Although surgical interventions for heart failure are still being explored and improved,their use in children is limited. This paper introduced several kinds of heart surgery support treatment methods: left ventricular reconstruction, mitral valve plasty and coronary artery bypass surgery.
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<p>Systolic anterior motion (SAM) is a common complication of mitral valve repair surgery and occasionally requires further treatment. A 56-year-old woman with severe mitral regurgitation accompanied by posterior leaflet prolapse underwent mitral valve plasty including hour-glass-shaped resection, chordal replacement, and interrupted commissural band annuloplasty. The mitral valve was exposed via a right-sided left atriotomy. We found a large thick P2-3 scallop (27 mm in height) with ruptured and elongated chordae. After repair, transesophageal echocardiography (TEE) revealed SAM of the anterior mitral leaflet and severe mitral regurgitation upon weaning from the cardiopulmonary bypass. Although catecholamine was discontinued and volume loading applied, the SAM did not improve. We decided to revise the mitral plasty. Therefore, although the height of the P3 scallop after resection remained 17 mm, neochordae were placed once more on the basal side of the posterior leaflet, and the leaflet was shortened by placing a continuous suture near the annulus. This reduced the height of the posterior leaflet and moved the co-aptation line posteriorly. After this repair, TEE showed that the SAM had disappeared. Thus, repositioning the neochordae and shortening the posterior leaflet by applying a continuous suture effectively and rapidly eliminated the problem.</p>
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<b>Objective</b> : The aim of this study is to describe a series of patients undergoing reoperation due to hemolytic anemia after mitral valve surgery and assess the mechanisms and surgical outcomes. <b>Methods</b> : Between 2009 and 2014, we performed redo mitral valve surgery in 11 patients who had refractory hemolytic anemia after mitral valve surgery at Kyoto University Hospital. The mean age of the patients was 72.2±6.8 years old, and there were 5 men. <b>Results</b> : Preoperative echocardiography demonstrated that only 3 patients had ≥ grade 3 mitral regurgitation (MR), the rest of the patients had only mild to moderate MR. The mechanisms of severe hemolysis included paravalvular leakage (PVL) after mitral valve replacement (MVR) in 8 patients, structural valve deterioration (SVD) after MVR using a bioprosthesis in one, and residual/recurrent mitral regurgitation after mitral valve plasty (MVP) in two. All the patients except one (re-MVP) underwent MVR. The mean interval between previous operation and current operation was 14.1±9.4 years in post-MVR cases, and 2.0±1.9 years in post-MVP cases. There were three late deaths, one of which was due to cardiac death (exacerbation of heart failure due to pneumonia). There was one patient who required re-MVR for recurrent hemolysis due to PVL after MVR. <b>Conclusion</b> : Although hemolytic anemia after mitral valve surgery is rare, it often requires reoperation regardless of the degree of MR at late follow-up period. Thus, patients after mitral valve surgery should be carefully followed-up.
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Giant left atrium (LA) in association with mitral valve disease is a significant risk factor for mortality and morbidity. It may cause obstruction of the bronchus, pulmonary artery, inferior vena caval orifice, or left ventricle, and has also required prolonged hospital stay. We describe our experience of left atrial reduction by means of circular LA resection concomitant with mitral valve plasty in 2 children with severe mitral regurgitation (MR) and giant LA. Case 1 was a 1-year-old boy, who had severe MR and giant LA, presenting with left bronchial obstruction. He underwent mitral valve plasty and circular LA resection. His LA volume, which was calculated using enhanced chest CT examination, was decreased by 23% postoperatively, comparing that before the operation. The cardiothoracic ratio on chest X-ray changed from 60% to 49%, and his sequential symptoms from giant LA disappeared. His postoperative course was uneventful and he was discharged on postoperative day 21. Case 2 was a 12-year-old girl with severe MR and giant LA. Her LA together with the sternum and spine compressed the right atrium and caused right heart failure. She underwent mitral valve plasty and circular LA resection. Her LA volume was decreased by preoperative 22%. Cardiothoracic ratio on chest X-ray changed from 63% to 57%. Her sequential symptoms from giant LA disappeared. Her postoperative course was uneventful and she was discharged 28 days after the operation. The circular LA resection technique reduced LA volume effectively, and the patients became free of clinical symptoms. Even in children, this procedure should be indicated in selective cases who presented clinical symptoms caused by the expanded LA.
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An 80-year-old woman underwent lower and middle lobe resections of right lung in 1990 and 1998 because of lung cancers. There was no recurrence. In 2009, she presented with exertional dyspnea, and echocardiography showed grade III mitral regurgitation (MR). We diagnosed with congestive heart failure caused by MR. Her chest CT showed her mediastinum was shifted to the right and her heart was in the right thoracic cavity. We performed mitral valve plasty via right 7th intercostal thoracotomy. Post-operative respiratory condition was stable and she was extubated on the first postoperative day. Post-operative UCG showed trivial MR. She was discharged on the 14th day.
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Left atrial aneurysm (LAA) is extremely rare. We report a surgical case of LAA complicated with mitral regurgitation (MR) and severe heart failure. A 71-year-old man presented dyspnea and leg edema, followed by congestive heart failure. Transthoracic echocardiogram (TTE) showed moderate MR, deteriorated left ventricular function, and echo free space connecting to the posterior wall of the left atrium. Three-dimensional reconstruction of computed tomography (3D-CT) clearly showed the whole shape of the LAA and its location relating to surrounding structures. LAA was 5×6 cm, expanding to apex side, and originated from the posterior wall of left atrium between circumflex branch of the left coronary artery and coronary sinus. LAA wall extended to the mitral posterior annulus, causing annular deformity and MR. Mitral valve plasty and aneurysmorrhaphy were performed. Biventricular pacing leads were implanted for cardiac resynchronization therapy, because of severe heart failure. Postoperative 3D-CT showed reduction of the LAA with no deformity of coronary vessels. No MR was detected by postoperative TTE. The patient has recovered without any complication after our treatments.
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We report a case of mitral active infectious endocarditis in a 15-year-old boy successfully managed by folding plasty without any prosthetic devices. He was admitted to our hospital because of high fever and general fatigue. Echocardiography revealed a vegetation of 15×18 mm attached to the anterior commissure area of the mitral valve with severe mitral regurgitation. Brain MRI showed acute brain infarction without symptoms, and enhanced computed tomography also showed multiple infarctions of the spleen and the left kidney. <i>Staphylococcus aureus </i>was identified in the venous blood culture. We diagnosed active mitral infectious endocarditis with multiple systemic embolization and disseminated intravascular coagulation. After antibiotic therapy for 9 days, mitral valve surgery was performed with cardiopulmonary bypass and cold blood cardioplegia through a median sternotomy and a left atriotomy. A giant vegetation was attached to the damaged mitral leaflet of the AC to A1 and P1. The vegetation and damaged leaflet were removed by an ultrasonic aspirator and resected. Removal of the superficial vegetation with the aspiration method enabled preservation of more than half of the A1 and half of the P1 for valve repair. The anterior commissure annulus without a leaflet was reconstructed by compression suture. Furthermore, in a procedure similar to folding plasty, leaflet A1 was folded down and sutured to annulus P1, and a simple suture technique was involved to the left cut edges of leaflet A1 and P1. The postoperative course was uneventful. Two years after surgery, the patient was well with no recurrence of infection and trivial mitral regurgitation on echocardiography.
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In recent treatment of mitral regurgitation due to active infective endocarditis, significant attempts have been made to repair as much of the mitral valve as possible. In cases where the leaflet is damaged extensively because of infection, valve repair generally becomes difficult unless the defect is reinforced by glutaric aldehyde-preserved autologous pericardium. We report a case in which mitral valve plasty for mitral regurgitation was performed under these circumstances. A 27-year-old man was admitted to our hospital because of headache and persistent fever. Transthoracic echocardiography revealed a 13-mm friable vegetation attached to the anterior leaflet of the mitral valve with severe mitral regurgitation. Urgent surgery was performed based on a diagnosis of active infective endocartitis. After cardiopulmonary bypass was performed and the aorta was cross-clamped, a left atriotomy was carried out on the interatrial groove. Much vegetation was attached to the damaged mitral leaflet from A3 to P3, and prolapse of the commissural leaflet was observed. The vegetation and damaged leaflet were then removed. Removal of the superficial vegetations enabled preservation of more than half of the A3. The valve was repaired by the resection-suture technique without using the autologous pericardium, as glutaric aldehyde solution was not available. Mitral annuloplasty using a 28-mm physio ring was performed thereafter. The postoperative course was uneventful and without any residual regurgitation. Nine months after surgery, no recurrence of infection or mitral regurgitation was not observed.