Brief Case Description

The patient is a 65 year old lady who has reported increasing exertional dyspnea and fatigue for 3 months. Her past medical history is noncontributory. On physical exam, she has a grade 4/6 holosystolic murmur heard at the left apex.

Transthoracic echocardiography showed type II mitral dysfunction with severe mitral regurgitation, bileaflet prolapse, a dilated mitral annulus, a normal ejection fraction, and mild tricuspid regurgitation. Cardiac catheterization revealed no significant coronary artery disease.

Operative Procedure

Intraoperative Transesophageal Echocardiography

Intraoperative transesophageal echocardiography confirmed the preoperative echo findings, bileaflet prolapse with a centrally directed regurgitant jet. The anterior leaflet length was measured to be 29mm and the P2 segment of the posterior leaflet was 22mm.

Reconstructive Procedure

Robotically assisted mitral valve repair was performed.  Cardiopulmonary bypass was established via peripheral cannulation in the right femoral artery, right femoral vein, and right internal jugular vein.

The steps of the operation are shown in the following video.  Initial analysis of the valve revealed an abnormal antero-lateral papillary muscle.  We performed a chordal shortening procedure using Gore-tex suture.  We then performed an A3/P3 commisuroplasty.  A Cosgrove-Edwards partial annuloplasty band was secured to the posterior annulus.  Finally, a restrictive secondary chord to the anterior leaflet was excised.  Post-repair saline test showed symmetric leaflet coaptation with minimal regurgitation.

Postbypass Transesophageal Echocardiography

Postbypass mid esophageal four-chamber view showed a competent mitral valve with no residual regurgitation. Three-dimensional rendering of the mitral valve showed a competent mitral valve. The prosthetic ring was visualized and correctly inserted.