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.