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Mitral valve repair or replacement on the beating heart
1Department of Cardiovascular Surgery, University Medical Center, Ljubljana, Slovenia. borut.gersak@maat.si
Insights
Beating heart surgery allows mitral valve repair and replacement, even with coronary artery bypass grafting (CABG), in high-risk patients. This technique offers advantages like myocardial perfusion and avoids reperfusion injury, making it suitable for complex cardiac procedures.
Area of Science:
- Cardiovascular Surgery
- Cardiac Valve Repair and Replacement
- Off-Pump Coronary Artery Bypass Grafting
Background:
- Advancements in beating heart (off-pump) coronary artery bypass grafting (CABG) have enabled consideration of mitral valve procedures on a beating heart.
- This includes the possibility of performing mitral valve repairs and replacements concurrently with or independently of CABG.
Purpose of the Study:
- To evaluate the feasibility and outcomes of performing mitral valve surgery on a beating heart, with or without concomitant CABG.
- To assess the safety and efficacy of this approach in high-risk patients with compromised left ventricular function.
Main Methods:
- Coronary artery bypass grafting (CABG) was performed first on the beating heart without cardiopulmonary bypass when feasible.
- For valve procedures, the aorta was cross-clamped while maintaining beating-heart status via continuous warm, oxygenated blood coronary-sinus perfusion.
Main Results:
- The technique was applied to 23 patients with extremely low ejection fractions (78% NYHA class 4, 17% NYHA class 3).
- Procedures included mitral-tricuspid (11), mitral-aortic (7), mitral-tricuspid CABG (1), and mitral-aortic CABG (4).
- Total early mortality was 13% (3/23), with non-cardiac causes in two in-hospital deaths and one late death from prosthetic valve endocarditis.
Conclusions:
- Key advantages include myocardial perfusion, reduced cardiac workload, absence of reperfusion injury, and the ability to test mitral valve repair under physiological conditions.
- This beating-heart approach is a viable option for valve operations or combined procedures in high-risk patients with low ejection fractions.
Background:
Beating heart (off-pump) coronary artery bypass grafting (CABG) techniques have led us to consider the possibility of performing mitral valve repairs and replacements (with or without CABG) on the beating heart.
Methods:
If CABG had to be performed in addition to the valve procedure, CABG was done first on the beating heart without cardiopulmonary bypass, if possible. For the valve procedure, the aorta was cross-clamped and the beating-heart status was maintained throughout the whole procedure with continuous, warm, oxygenated blood coronary-sinus perfusion.
Results:
We used this technique in 23 patients with extremely low ejection fractions, 78% of whom were in New York Heart Association (NYHA) class 4 and 17% of whom were in New York Heart Association (NYHA) class 3. The procedures were: mitral-tricuspid (11 patients), mitral-aortic (7 patients), mitral-tricuspid CABG (1 patient), and mitral-aortic CABG (4 patients). The total early mortality was 13% (3 of 23 patients). Two were in-hospital deaths. One patient with triple-vessel disease and acute mitral insufficiency (AMI) on intra aortic balloon pump had been operated on six days after AMI. The cause of death was systemic meticillin resistant staphylococcus aureus infection. (Eight days prior to our operation, arthrodesis of the talocrural joint was performed by an orthopedic surgeon.) The other death was a female patient who was operated on after previous multiple cerebrovascular infarctions (CVIs) (cause of the death was CVI). In addition, one patient died one month after the operation because of prosthetic valve endocarditis on aortic and mitral valves (silver-coated silzone aortic and mitral valves were implanted because of chronic latent asymptomatic tibial osteitis). None of these deaths were cardiac related.
Conclusions:
The main advantages of beating heart surgery are: 1) the perfused myocardial muscle, 2) the heart not doing any work, 3) no reperfusion injury, 4) the possibility for ablation of atrial fibrillation on the beating heart, and 5) testing of the mitral valve repair is done in real physiologic conditions in the state of left ventricle beating tonus. The procedure could be the procedure of choice for the valve operation or combined operations in high-risk patients with low ejection fractions.