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Re-operation for the mechanical valve obstruction with a beating heart technique in an elderly patient with compromised ventricular function/ Bozulmus ventrikul fonksiyonlu yash hastada carpan kalp teknigi ile mekanik kapak obstruksiyonu icin reoperasyon.

Introduction

Conventional mitral valve replacement (MVR) consists of cardiopulmonary bypass (CPB), cross-clamping, and cardioplegia. Reperfusion injury is a phenomenon that can occur in classic technique (1). Beating heart valve surgery by perfusing the heart continuously with blood eliminates the ischemia and avoids reperfusion injury. In addition, this technique may have other advantages, as the heart is under more physiologic condition than the cardioplegic arrested state especially in patients who have compromised ventricular functions (2-4).

Case report

An 85 years old male patient admitted with symptoms of dyspnea and palpitation. He underwent MVR operation 2 years ago.

No mechanical valve sounds were detected during cardiac auscultation. Patient was in NYHA functional class III. Electrocardiography revealed atrial fibrillation and bilaterally lung edema observed on chest X-ray. Echocardiography showed 13/6 mmHg peak/mean mitral diastolic gradient, and no leaflet motion on the prosthetic valve. Also, ejection fraction (EF) was calculated as 30% and pulmonary artery pressure (PAP) was measured as 60 mmHg. During X-ray scope examination no leaflet motion was observed.

Emergency re-operation was performed. Before the re-median sternotomy, femoral artery and vein were explored. Aortic and bi-caval cannulation were performed. Coronary sinus (CS) and right upper pulmonary vein were also cannulated. Operation was started with the use of standard CPB without cross-clamping the aorta. Pulmonary vein was continuously vented. When the patient was put in the Trendelenburg position, the left atrium was opened. We observed that the leaflets of prosthesis were stuck. During excision of the valve and the left atrial thrombectomy aorta were clamped and continuous retrograde CS perfusion with oxygenated warm blood was started. Retrograde CS perfusion rate was kept between 400-500 ml/min and perfusion pressure kept between 50-60 mmHg. Possible myocardial ischemia was monitored electrocardiographically and with measuring of blood gas changes of the returned blood from the aortic venting in every 10 minutes during CS perfusion. Prosthetic valve was excised and bileaflet mechanical valve was replaced. After closing the left atrium and de-airing of the heart, aortic cross-clamp was released and retrograde perfusion was stopped. Weaning from the CPB occurred smoothly with 5 mcg/kg/min dopamine support. Operation was performed without any complication and there was no postoperative cerebrovascular event.

Discussion

Although major technological advances have been made in myocardial protection, perioperative adverse affects caused by myocardial ischemia and reperfusion injury have not been completely eliminated. Therefore, great effort is made to prevent reperfusion injury during such procedures (5, 6). Especially cardioplegic arrest of the heart in high-risk situations as elderly patients, compromised ventricle, re-operations and high PAP may make weaning from the CPB problematic. Cardiac dysfunction may be caused by myocardial edema intrinsic to the diastolic state of the arrested heart and due to the some degree of reperfusion injury. In contrast, keeping the heart beating, results in less myocardial edema and better cardiac function (7).

The right ventricular protection, either during the retrograde cardioplegia or CS perfusion with blood is defined a problem in the literature (8). However, in comparison with other techniques, this technique has important differences that minimize this risk (2-4, 9, 10). The optimal safe perfusion pressure during retrograde CS perfusion is closely related to CS perfusion flow. Matsumoto et al. presented no complications related to retrograde CS perfusion during high pressures (60 to 80 mmHg) (2).

In this procedure, motion of the heart and removal of air may be problematic. Well decompression of the heart caused by cardiac venting resulted in quality of visual field equal to that conventional technique. De-airing was performed continuously from the aortic venting cannula until the end of the CPB. Postoperatively creatine kinase -MB levels were measured in 6, 12, 24, and 48 hours and were found to be in normal ranges. The aorta was cross-clamped for 20 minutes with the total bypass time of 95 minutes. The aortic cross-clamp time is not the ischemic time, because the heart was receiving blood all through this time period. One of the advantages of this technique is the ease of weaning patients from CPB (4).

Conclusion

We believe that beating hearttechnique is a good surgical option for mitral valve disease. This technique provides more physiologic conditions than cardioplegic arrested state. This advantage makes benefits especially for patients with compromised left ventricular functions who have high risk of myocardial injury with the conventional technique.

References

(1.) Weman SM, Karhunen PJ, Jarvinen AA, Salminen US. Reperfusion injury associated with one-fourth of deaths after coronary artery bypass grafting. Ann Thorac Surg 2000; 70: 807-12.

(2.) Matsumoto Y, Watanabe G, Endo M, Sasaki H, Kasashima F, Kosugi I. Efficacy and safety of on-pump beating heart surgery for valvular disease. Ann Thorac Surg 2002; 74: 678-83.

(3.) Kaplon RJ, Pham SM, Salerno TS. Beating-heart valvular surgery: a possible alternative for patients with severely compromised ventricular function. J Card Surg 2002; 17: 170-2.

(4.) Gersak B, Sutlic Z. Aortic and mitral valve surgery on the beating heart is lowering cardiopulmonary bypass and aortic cross clamp time. Heart Surg Forum 2002; 5:182-6.

(5.) Buckberg GD. Oxygenated cardioplegia: blood is a many splendored thing. Ann Thorac Surg 1990; 50:175-81.

(6.) Mauny MC, Kron IL. The physiologic basis of warm cardioplegia. Ann Thorac Surg 1995; 60: 819-23.

(7.) Mehlhorn U, Allen SJ, Adamus DL, Davis KL, Gogola GR, Warters RD. Cardiac surgical conditions induced by B-blockade: effect on myocardial fluid balance. Ann Thorac Surg 1996; 62:143-50.

(8.) Savitt MA, Singh T, Agrawal S, Chounday A, Chaugle H, Ahmed A. A simple technique for valve replacement in patients with a patent left internal mammary artery bypass graft. Ann Thorac Surg 2002; 74: 1269-70.

(9.) Gersak B. A Technique for Aortic Valve Replacement on the Beating Heart with Continuous Retrograde Coronary Sinus Perfusion With Warm Oxygenated Blood. Ann Thorac Surg 2003; 76:1312-4.

(10.) Cicekcioglu F, Tutun U, Babaroglu S, Aksoyek A, Tosya A, Tuncel C, et al. Beating heart mitral valve replacement with retrograde coronary sinus perfusion technique. J Cardiovasc Surg (Torino) 2006; 47: 575-9.

Ferit Cicekcioglu, Ufuk Tutun, Seyhan Babaroglu, Aysen Aksoyek, Ali Ihsan Parlar, Ahmet Tulga Ulus, Salih Fehmi Katircioglu

Cardiovascular Surgery Clinic, Turkiye Yuksek Ihtisas Hospital, Ankara, Turkey

Address for Correspondence/Yazisma Adresi: S.Fehmi Katircioglu MD., Turkiye Yuksek Ihtisas Hospital Department of Cardiovascular Surgery 06100, Sihhiye, Ankara, Turkey Phone: +90 312 30611 88 Fax: + 90 312 229 58 68 E-mail: fehmiege@yahoo.com
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Author:Cicekcioglu, Ferit; Tutun, Ufuk; Babaroglu, Seyhan; Aksoyek, Aysen; Parlar, Ali Ihsan; Ulus, Ahmet T
Publication:The Anatolian Journal of Cardiology (Anadolu Kardiyoloji Dergisi)
Article Type:Case study
Geographic Code:7TURK
Date:Oct 1, 2008
Words:1054
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