Case presentation
A 63 years-old woman was admitted at our institution in March 2020, with
diagnosis of severe myxomatous mitral regurgitation. Pre-operative
echocardiography showed a prolapse of both mitral leaflets and annular
dilatation, preserved systolic function and normal kinesis. Coronary
angiography was normal.
A mitral valve repair through a minimally invasive approach at the right
fourth intercostal space was performed. Valve repair was achieved by
posterior leaflet resection and annuloplasty with an open band
(Futureband, Medtronic Inc.). Custodiol cardioplegia was used. No aortic
insufficiency and good delivery of cardioplegia was assured.
Cardiopulmonary bypass time was 114 minutes, and cross-clamp time was 82
minutes. Conversion to a full sternotomy was required due to a sudden
bleeding caused by ruptured left atriotomy. No re-clamping was needed.
Post-op transesophageal echocardiogram (TEE) showed good repair with
only trivial mitral regurgitation and good cardiac function.
On the first post-operative day (POD), the patient suffered generalized
tonic–clonic seizures. Haemodinamic instability occured and inotropic
support was required (norepinephrine 0,08 mcg/Kg/min, epinephrine 0,04
mcg/Kg/min)
TEE showed a severely reduced left ventricle ejection fraction (30%).
Basal segments appeared hyperkinetic while apical segments were
hypo/akinetic with typical ballooning aspect, no SAM was reported. EKG
showed diffuse ST elevation. Due to an increase of myocardionecrosis
markers, coronary angiography was repeated, with no new findings. Then,
Takotsubo Syndrome was suspected, and pharmacological hemodynamic
support was continued, adding levosimendan at 0,1 mcg/Kg/min.
On the 6th POD severe hypotension re-occurred. TEE showed slight
improvement in systolic function (LVEF 44%) with persistent apical
akinesis but this time with persistent hyperkinesis of the base of the
left ventricle causing a new onset of SAM of the anterior mitral leaflet
with left ventricle outflow tract obstruction and severe mitral
regurgitation [Figure 1]. Consequent pulmonary artery hypertension
and right ventricle dysfunction complicated the clinical condition. No
lung injury or pulmonary oedema were present.
Inhaled nitric oxide (NO) at 20 parts per million (ppm) and sildenafil
IV were immediately added.
No extracorporeal membrane oxygenation (ECMO) was needed. Aggressive
fluid administration was started despite the right ventricle dysfunction
and IV Esmolol was titrated as soon as the hemodynamic condition allowed
a progressive reduction of inotropes (norepinephrine 0,02 mcg/Kg/min,
epinephrine 0,02 mcg/Kg/min). After slow iNO weaning the patient was
maintained on Sildenafil infusion until the tenth POD and oral
beta-blocker therapy with bisoprolol until discharge.
The patient gradually improved, and the 21st POD echocardiogram showed a
recovered LVEF (55%), no SAM and only slight apical hypokinesia with
mild mitral regurgitation [Figure 2]. After 5 days the patient was
discharged for rehabilitation in good conditions.