Article Type : Research Article
Authors : Jmaa HB, Seddik M, Dammak A, Mejri S, Jawadi W, Gueldich M, and Frikha I
Keywords : Mitral valve replacement; Left ventricular dysfunction; Beating heart
Beating
heart valve replacement is an interesting technique which can be made under
sternotomy or thoracotomy. It is an alternative technique in patients with poor
left ventricular function, because it avoids the ischemic component of
cardioplegia and an arrested heart by keeping the heart beating will go a long
way in reducing iatrogenic damage to the heart. A beating heart valve
replacement is an interesting technique that can be performed sternotomy or
thoracotomy. It is an alternative technique in patients with left weakness
ventricular function, as it avoids the ischemic component of cardioplegia and
Cardiac arrest by maintaining the heartbeat will go a long way in reducing
iatrogenic Heart damage. We report the case of a 43-year-old man with no signi?cant
past medical history, who was admitted to the cardiology department for
invalidate dyspnoea. Physical examination showed a diastolic murmur in the
cardiac auscultation. Electrocardiogram revealed atrial fibrillation.
Transthoracic echocardiogram revealed a left ventricle dysfunction with an
ejection fraction of 30 %, and a severe mitral stenosis and regurgitation with
remained and calcified mitral leaflets, with a tricuspid insufficiency and the
tricuspid annulus measuring 44 mm. He was operated under a median sternotomy,
normothermic cardiopulmonary bypass, and through a left atriotomy, mitral valve
observation revealed calcified leaflets and subvalvular apparatus. The mitral
valve was resected and a mechanical prosthesis was implanted with simple sutures.
A tricuspid annuloplasty was performed with the technique of De Vega. Then, the
left and right atrium were closed and the patient was weaned from
cardiopulmonary bypass. Intraoperative transesophageal echocardiography showed
moderate regurgitation. Weaning from cardiopulmonary bypass was not
complicated, and the hemodynamic status was stable under low doses of
catecholamins. The postoperative course was uneventful. Predischarge
echocardiographic evaluation revealed a left ventricular ejection fraction of
35 % and mild tricuspid regurgitation, and mitral prosthesis without
paraprosthetic regurgitation. At his 3-month follow-up, the patient was in good
clinical condition without chest pain or dyspnoea.
Beating
heart valve replacement is an interesting technique which can be made under
sternotomy or thoracotomy, and can preserve the left ventricular function in
the patients with cardiac dysfunction, and patients with multiple-time redo
mitral valve surgery [1]. We report the case of a 43-year-old male patient who
underwent successfully mitral replacement and tricuspid annuloplasty with
beating heart and cardiopulmonary assistance.
A 43-year-old man with no signi?cant past medical history was admitted to the cardiology department for invalidate dyspnea. Physical examination showed a diastolic murmur in the cardiac auscultation. Electrocardiogram revealed atrial fibrillation. Transthoracic echocardiogram revealed a left ventricle dysfunction with an ejection fraction of 30 %, and a severe mitral stenosis and regurgitation with remained and calcified mitral leaflets, with a tricuspid insufficiency and the tricuspid annulus measuring 44 mm. Because of the low ejection fraction of the left ventricle, and the high operative risk of the cardioplegia and cardiac arrest, we decided to perform mitral replacement and tricuspid annuloplasty with beating heart and cardiopulmonary assistance. After a median sternotomy, normothermic cardiopulmonary bypass was initiated. Through a left atriotomy, mitral valve observation revealed calcified leaflets and subvalvular apparatus. The mitral valve was resected and a mechanical prosthesis was implanted with simple sutures. A tricuspid annuloplasty was performed with the technique of De Vega. Then, the left and right atrium were closed and the patient was weaned from cardiopulmonary bypass. Intraoperative transesophageal echocardiography showed moderate regurgitation (Figure 1).
Figure 1: Intra-operative trans-esophageal echocardiogaphy.
Clamp
time and cardiopulmonary bypass time were 33 and 100 minutes, respectively.
Weaning from cardiopulmonary bypass was not complicated, and the hemodynamic
status was stable under low doses of catecholamins. The postoperative course
was uneventful. Predischarge echocardiographic evaluation revealed a left
ventricular ejection fraction of 35 % and mild tricuspid regurgitation, and
mitral prosthesis without paraprosthetic regurgitation (Figure 2). The patient
was discharged asymptomatic on postoperative fifth day. At his 3-month
follow-up, the patient was in good clinical condition without chest pain or
dyspnoea.
Any technique that avoids the ischemic component of heart paralysis and cardiac arrest by maintaining the heartbeat it will go a long way in reducing iatrogenic damage to the heart. In addition to the benefits of protecting the heart muscle, the valves of the beating heart are on the pump operations may have other advantages and utilities [2,3].
Figure 2: Post-operative echocardiography.
Eliminates
ischemia Created by keeping the heart beating throughout the process conducted
one study to evaluate the outcome of the mitral valve replacement of a beating
heart in patients with severe chronic and insidious mitral regurgitation
Ventricular dysfunction, by comparing two identical groups of patients: a group
of the underwent a crown replacement with a beating heart technique, and the
group that underwent Cardiac arrest and cardiac palsy surgery. They concluded
better left ventricular function early after surgery than the mitral valve
replacement with warm cardiac arrest. Also, in this study, capacitor means the
stay in the care unit was significantly longer in the first control group (3.60
± 1.19) compared to Second multiplication group (2.40 ± 0.68) reported that
creatinine kinase and LDH values for the beating group was lower than the
cardiac arrest group values. In the study of, there were no significant
surgical deaths Complications such as stroke or perioperative myocardial
infarction in either group [4-6]. Reported a series of 59 patients who
underwent multiple valve surgery with beating heart technique. This technique
can also be indicated in redo patients under sternotomy or thoracotomy reported
that 28 rheumatic patients underwent second-time redo mitral valve surgery
through median sternotomy, and 26 patients (93%) were NYHA CHF class 3 or 4.
There were 4 (14%) hospital mortalities. They concluded that deaths were
related to poor ventricular function and not to the number of previous
operations. However, this technique has technical difficulties which are mainly
due to flooding the field with blood and inability to suture safely with the
contracting annulus, and the difficulty of avoiding air embolism [7,8].
Beating
heart mitral valve surgery looks to be associated with better left ventricular
function early postoperatively than in MVR using cardiologic arrest. Further
studies are needed to fully evaluate the potential bene?ts of this method to
preserve ventricular function in multiple valvular surgery.