Pump Assisted Beating Mitral Valve Replacement and Tricuspid Annuloplasty: A Case Report and Review of the Literature

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.

1. Suzuki Y, Pagani FD, Bolling SF. Left thoracotomy for multiple-time redo mitral valve surgery using on-pump beating heart technique. Ann Thorac Surg. 2008; 86: 466-471.
2. Bedi HS. Mitral valve replacement on a bearing heart. Indian Heart J. 2003; 55: 370-372.
3. Katircioglu SF, Cicekcioglu F, Tutun U, Parlar AI, Babaroglu S, Mungan U, et al. On-pump beating heart mitral valve surgery without cross-clamping the aorta. J Card Surg. 2008; 23: 307-311.
4. Mahmoud A, Elsherif E, Ayyad MAKS, Elsawy H, Elwahab AA.  Outcome of pump assisted beating mitral valve replacement in patients with chronic severe mitral regurgitation and left ventricular dysfunction. A clinical randomized trial. J Egyptian Society Cardio-Thoracic Surg. 2018; 257-263.
5. Gersak B. Mitral valve repair or replacement on the beating heart. Heart Surg Forum. 2000; 3: 232-237.
6. Ricci M, Igor F. B. M, Suarez M.R, Brown M, Alba J, Salerno T.A. Multiple Valve Surgery with Beating Heart Technique. Ann Thorac Surg. 2009; 87: 527-531.
7. Magilligan DJ Jr, Lam CR, Lewis JW Jr, Davila JC. Mitral valve–the third time around. Circulation. 1978; 58: 136-138.
8. Thompson MJ, Behranwala A, Campanella C, Walker WS, Cameron EW. Immediate and long-term results of mitral prosthetic replacement using a right thoracotomy beating heart technique. Eur J Cardiothorac Surg. 2003; 24: 47-51.