Mitral Valve Surgery with Concomitant AVR - Complex …
As the approach was made through the left atrial appendage, the mitral valve was visible without retraction. A few stitches were placed to retract the incised edges of the left atrial appendage (), and the mitral valve was excised. The valve was thick and puckered, with gross subvalvular fusion. A 25-TTK Chitra Heart Valve mechanical prosthesis (TTK Healthcare Ltd; Chennai, India) was placed in the mitral position with 2–0 Ticron pledgeted sutures (). The left atrial appendage was de-aired and closed. The aortic root was vented and the cross-clamp released. The patient was rewarmed and weaned from cardiopulmonary bypass with only 2.5 μcg/kg/min of dobutamine support. He was in atrial fibrillation, with a controlled ventricular rate and stable hemodynamics. The patient's postoperative recovery was uneventful. Five months after surgery, the patient was asymptomatic and the mitral prosthesis was functioning well.
Mitral Valve Surgery with Concomitant AVR ..
We report the case of a patient with mesocardia, mitral restenosis, and mitral regurgitation. He had undergone an open mitral valvotomy 4 years earlier and, therefore, presented us with a problematic approach to the mitral valve. In such cases, access to the mitral valve is almost impossible due to the position of the valve, which is more posterior and to the left of a normal valve, and due to adhesions from the previous surgery. We approached the mitral valve through the left atrial appendage and replaced the mitral valve with a mechanical prosthesis.
In January 2010, a 69-year-old woman with rheumatic mitral stenosis, mitral insufficiency, and chronic atrial fibrillation underwent MVR with a 27-mm bileaflet mechanical prosthesis (St. Jude Medical, Inc.; St. Paul, Minn). We used a chordal-sparing technique, resecting the calcified central portion of the anterior leaflet and attaching its remnants to the mitral annulus at the 10- and 2-o'clock positions. We partially excised the thickened posterior leaflet at its leading edge, performed superficial débridement of calcium deposits on the posterior leaflet and the annulus, and divided the posterior leaflet in its mid portion to enable secure seating of the prosthesis. We sutured the valve in place with interrupted 2-0 TiCron™ mattress sutures (Covidien Syneture; Mansfield, Mass) on Teflon pledgets, passed from the ventricular side through a small imbrication of posterior-leaflet tissue and then through the annulus. Using echocardiographic monitoring in the 4-chamber view, we de-aired the heart through the aortic root vent with ballottement of the heart and manual inversion of the left atrial appendage. At no time was the heart elevated from the pericardium to achieve de-airing. Immediately after the termination of cardiopulmonary bypass (CPB), brisk bleeding occurred from the posterior aspect of the heart.