Totally endoscopic minimally invasive mitral valvuloplasty with a beating heart for treatment of papillary muscle rupture

Central MessageTotally endoscopic minimally invasive mitral valvuloplasty with beating heart in the papillary muscle rupture accompanied severe failure is effective and reliable.See Commentary on page XXX. Totally reliable. See A 64-year-old man who presented (PMR) after acute myocardial infarction cardiogenic shock was emergency transferred to our institution support of intra-aortic balloon pump (IABP) extracorporeal membrane oxygenation (ECMO). The patient had undergone percutaneous coronary intervention 3 days earlier for right artery occlusion. Electrocardiogram admission revealed inferior infarction. Chest radiograph pulmonary edema (Figure 1, A). Echocardiography demonstrated regurgitation posterior leaflet flail caused by PMR B C). Besides, liver injury kidney requiring dialysis. Society Thoracic Surgeons score predicted risk operative mortality high, at 39.795%. Emergency totally (MVP) performed (Video 1). intubated a single-lumen endotracheal tube. Normothemic cardiopulmonary bypass established via femoral vein while ECMO maintained self-circulation. limited anterolateral thoracotomy then through fourth fifth intercostal space thoracic cavity insufflated carbon dioxide reduce intracardiac air. Intraoperatively, ruptured heads resection 2, A), artificial chordae tendinae implantation B), commisuroplasty between A3 P3 C), annuloplasty 28-mm Carpentier-Edwards Physio II semirigid complete ring D). Keeping valve open until left atrium closes could help empty air ventricle avoid potential embolism. Cardiopulmonary weaned off smoothly, cannulations were reconnected ECMO. Postoperative transesophageal echocardiography showed trivial recovered stably; conscious postoperative day 2; from ECMO, IABP, ventilator 5, 7, 21, respectively. died sepsis biliary tract infection 32 surgery. life-threatening complication (30-day up 39.3%). It results regurgitation, often shock, both medical treatment surgical intervention.1Massimi G. Ronco D. De Bonis M. Kowalewski Formica F. Russo C.F. et al.Surgical post-infarction rupture: multicentre study.Eur J Cardio Thorac Surg. 2022; 61: 469-476Crossref Scopus (11) Google Scholar Mechanical circulatory assistance, including IABP are needed. MVP appears be viable alternative replacement PMR, given that it has lower mortality, shorter hospital stays, similar incidence short-term complications.2Kilic A. Sultan I. Chu Wang Y. Gleason T.G. Mitral surgery outcomes 1342 patients Database.Ann 2020; 110: 1975-1981Abstract Full Text PDF PubMed (20) However, still preferred strategy most surgeons cases (about 80%), which maybe due complexity difficulty prolonged operation time, controversial reintervention.3Hamid U.I. Aksoy R. Sardari Nia P. repair rupture.Ann Cardiothorac 11: 281-289Crossref (3) Conventional cardiac arrest carried high burden associated morbidity poor ventricular function, especially case. Considering better protection, prosthesis thrombosis under support, accumulated extensive experience MVP, we finally chose perform approach. Continuous perfusion throughout alleviate damage hypothermia, edema, ischemia-reperfusion injury. technique fibrillation arrest. may oxygen delivery subendocardium thus provides suboptimal protection.4Romano M.A. Haft J.W. Pagani F.D. Bolling S.F. Beating reoperative surgery: safe alternative.J Cardiovasc 2012; 144: 334-339Abstract (39) These reasonable explanations group. Although excellent exposure obtained incision interatrial groove combined continuous drainage, more or less increases returned blood volume during operation, augmented. Measures (such as esmolol) rate excessive negative pressure would helpful. particular concern embolism; however, there controversy whether stroke.5Zhang H. Xu H.S. Wen B. Zhao W.Z. Liu C. Minimally previous sternotomy giant ventricle.J 15: 122Crossref Generally, aortic does not easily diastolic systolic periods an because root much higher than atmospheric pressure. might systemic embolism avoiding crossclamp. Carbon insufflation displace air, drainage ascending aorta, adequate head-down position also contribute reducing helpful achieve function. improve