Mitral valve repair with CABG

A 55-year-old male with severe non-rheumatic mitral regurgitation, severe pulmonary hypertension, diabetes and coronary artery disease, was admitted for mitral valve repair and coronary bypass surgery. In view of his severe pulmonary artery hypertension, he was admitted and treated with Sildenafil (phosphodiesterase inhibitor) before taken up for surgery. His coronary angiogram showed critical occlusion in circumflex artery.

Surgical Procedure

Under cardiopulmonary bypass and cardioplegic arrest, mitral valve was inspected. He had prolapse of P2-P3 segments and chordae rupture at P2 segment. Quadrangular resection and repair of PML was done. Mitral annuloplasty was done using 30 mm Carpentier-Edwards Physio annuloplasty ring. SVG graft was done to OM2 circumflex artery. Came off bypass with stable rhythm and mild mitral regurgitation (MR) on TEE. De-cannulation done. While securing complete hemostasis, his blood pressure improved and then TEE showed moderate MR at P3 segment.

The question was whether to leave it and accept this MR or go back and get a perfect repair. The team decided to re-do the repair. Hence the patient was re-heparinized, cannulated, went on CPB, cardioplegia was given, left atrium was opened. P3 segment was found to be further prolapsed. This segment was re-fixed with neo-chordae and additional Alfieri stitch. Came off bypass. Post-op TEE showed no MR.

The patient became COVID positive in the post-op period and had an extended stay for further 10 days. Post-op follow-up showed no MR and the patient is now back at work.

Discussion

Degenerative mitral valve disease is the most common organic mitral valve pathology. Usually degenerative mitral valve pathology does not progress to clinically significant. But patients who develop symptoms attributable to MR have adverse prognosis and they need timely surgery. With surgery, essentially unavoidable in these patients, mitral valve repair has demonstrated superior short and long-term outcomes. We should try to avoid mitral valve replacement in these patients. Mitral valve repair has been consistently associated with lower risk of thromboembolism and improved survival. The method of mitral valve repair was evolved and improved. On the basis of operative findings, we resect and repair, consider neochordae insertion, placing an Alfieri stich, or doing a combination of these procedures. Once repair is attempted, we must almost always try to reach 100% perfection. At any cost, these patients should not have residual MR as this may progress and the patient may need re-do surgery.

In this case, we partially agreed to accept the mild MR in post-repair period, but within no time, TEE showed worsening MR. There should not be any hesitation to put the patient back on CPB and re-repair the mitral valve to get best results.

Mitral valve repair – perfection