Operative procedures
A cardiopulmonary bypass (CPB) was initiated with the ascending aorta and superior and inferior vena cava under general anesthesia. The hematoma at the site of coronary perforation and thinness at D1, D2, and the apex indicated a broad MI. We performed coronary artery bypass grafting on five vessels with the left internal thoracic artery and saphenous vein, mitral annuloplasty with 32 mm of CG Future (Medtronic, Dublin, Ireland), and LVPWP through a left atriotomy over the mitral valve (MV). The operative, CPB, and cross-clamp times were 544 min, 297 min, and 194 min, respectively. Surgical technique: LVPWP (Figure 3a)
We approached the MV through left atriotomy and from over the MV. During LVPWP, we sutured the trabeculae carneae with five horizontal mattress stitches (4-0 polyvinylidene fluoride sutures with small felt strips) to lightly plicate only the endocardial side, not in the deep layer, from the apical side of the bilateral papillary muscle to under the MV.
The hemodynamics stabilized gradually, and the patient was weaned from the Impella CP after 10 postoperative days (POD), extubated after 16 POD, discharged from the intensive care unit after 20 POD, and transferred to another hospital for further rehabilitation after 51 POD. Echocardiography performed 1 month and 1 year postoperatively showed MR was controlled to a trivial level despite a low EF and global hypokinesis (Figure 3b), and there was no recurrence of heart failure at 1 year postoperatively.