Cardiac autotransplantation for mitral valve replacement

We present an unusual case of a 69-year-old patient with severe mitral valve regurgitation and extensive coronary artery disease who required mitral valve replacement and myocardial revascularization. With the patient on cardiopulmonary bypass, distal vein grafting was performed first. This procedure was followed by a transatrial transseptal approach to the mitral valve, but visualization of valve structures was extremely difficult. Following the partial excision of the posterior leaflet and the placement of a few pledgeted annular sutures on which traction was applied, access to the mitral annulus remained impossible. There appeared no option but to explant the heart and perform the mitral valve replacement ex vivo. Cardiac explantation was performed by transecting the aorta and pulmonary artery and completing the already extended right and left atriotomies. Cold blood cardioplegic solution was administered intermittently into the coronary sinus during the period when the heart was ex vivo. A porcine bioprosthesis was easily seated into the mitral annulus. Cardiac reimplantation consisted of repair of the previously divided atria, and end-to-end anastomoses of both the aorta and the pulmonary artery. While rewarming was taking place, the 3 proximal vein graft anastomoses were performed. Temporary and permanent epicardial pacing leads were placed. Total ischemic time was 299 minutes, and the period on cardiopulmonary bypass was 359 minutes. The heart sustained good hemodynamics, and after full functional recovery, the patient was discharged home and remained well for 7 years. In view of this experience, a questionnaire was mailed to >3000 cardiothoracic surgeons, and responses were obtained from 1120. Inadequate mitral valve exposure had been experienced by 70%. To provide increased exposure, 50% had extended the initial atrial incision both horizontally and perpendicular to the atrial groove, 17% had divided the superior vena cava, 1% had divided the inferior vena cava, and 1% had divided both cavae. Furthermore, 4% of surgeons reported being forced to abandon the operation in 71 patients because of inadequate exposure. Three hundred twenty perioperative deaths were directly attributed to an incomplete surgical procedure. Explantation of the heart, with mitral valve replacement being performed ex vivo followed by reimplantation, should be considered when access to the mitral valve proves impossible with more standard techniques.