Case report
A 77-year-old female with symptomatic SMVS was admitted to a secondary referring Hospital. Trans-oesophageal echocardiography demonstrated a SMVS (valve area 0,9-1 cm2 and mean gradient of 17 mmHg), with commissural fusion, diffused calcification of the annulus and leaflets, and no mitral regurgitation. LVEF was 60% and there were no left atrial thrombi. Severe pulmonary hypertension (PAPs 85 mmHg) was identified.
After Heart-Team discussion, PMC was planned according with current ESC/EACTS Guidelines (1). The procedure was performed at the same admitting hospital with a high-volume interventional cardiology programme but no cardiac surgery onsite. After peripheral trans-venous catheterization, despite a continuous trans-oesophageal echocardiographic and radioscopic monitoring\sout, inadvertent catheter perforation of the right atrium and of the non-coronary sinus of the aortic root (Figure 1) was noted, resulting in transient haemodynamic decompensation.
Immediate intensive-care support allowed for haemodynamic stability, so patient could be emergently transferred to our centre and directly brought to our “stand-by” operating theatre.
Intraoperative assessment confirmed that angiographic catheter together with the supportive guide-wire perforated the roof of the right atrium, and the non-coronary sinus of the aortic root (Figure 2). Spontaneous formation of a pericardial clot prevented active bleeding. After standard aorto-bicaval cardiopulmonary bypass, aortic cross-clamping and cardioplegic arrest, the catheter and the guide-wire were removed, and the right atrial perforation was closed with a pericardial patch. After transverse aortotomy, non-coronary sinus was resected and substituted with bovine pericardial patch (XenoSure® Biologic Patch, LeMaitre Vascular, USA), followed by a conventional 25 mm bioprosthetic mitral valve replacement (EPIC™, St Jude Medical, Inc, St Paul, Minn). Given the extensive mitral annular calcifications, only partial posterior mitral annular decalcification was carried out, due to the risk of atrio-ventricular discontinuity and/or para-valvular leak.
Weaning from cardiopulmonary bypass support required high-dose inotropes, IABP, and inhaled NO due to persistent severe pulmonary hypertension with right ventricular dysfunction. A delayed-sternal closure approach was chosen to favour postoperative RV recovery.
Progressive postoperative recovery was noted, leading to sternal closure on 2nd POD, IABP-withdrawal on 7thPOD, and extubation on 10th POD. Transient acute kidney injury required dialysis. The patient was transferred to Rehabilitation Clinic on 48th POD with stable hemodynamic, no inotropic support, and a recovered renal function.
The patient was discharged home on 78th POD in healthy conditions, and she is alive at 7 months of follow-up in NYHA class I-II.