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The patient was a healthy 88-year-old male who had been in atrial fibrillation (AF) for 20 years, who presented with a large left atrium. He had undergone ascending aortic replacement, aortic valve replacement, mitral valve repair (MVr), and tricuspid valve repair in the past, during which the repair of the tricuspid valve was performed through the septum.
He subsequently showed signs of right heart failure and was reviewed by multiple medical centers across the United States. He was evaluated by cardiologist Chad Rammohan, who found very large atria and severe mitral regurgitation with a posterior jet. The mitral ring was positioned incorrectly, being unattached to the posterior annulus, with dehiscence from the annulus that was well visualized on transesophageal echocardiography (TEE), causing the ring to float over the valve.
Additionally, there was now an atrial septal defect (ASD) resulting from the transatrial approach to the repair of the tricuspid valve, with the severe mitral regurgitation (MR) directed across the atrial septal defect (ASD) causing right volume overload. This condition was not suitable for device closure due to a lack of a rim around the ASD. Furthermore, there was no possibility for mitral intervention via a transcatheter approach due to the dehiscence of the ring.
The tricuspid valve had moderate regurgitation, but its annuloplasty ring was in a reasonable position. The aortic valve was functioning normally. The computed tomography (CT) scan revealed that the right atrium was very close to the sternum, while the ascending aorta was positioned away from the sternum with a good amount of space. Additionally, the right atrium was enlarged and had such severe hypertension that it was pressing onto the sternum, causing the right atrial appendage to be pushed onto the sternum.
Thus, the operative plan was to place venous and arterial cannulation from the femoral vessels and to go on bypass when opening the sternum due to the high risk of atrial damage. A16-gauge venous cannula was placed into the superior vena cava (SVC) in the right neck. The sternum was opened, and only a small defect was made on the right atrium, which was closed.
Due to adhesions between the ascending aortic graft and the pulmonary artery (PA), Dr. Gaudiani decided to cross-clamp the aorta and the PA together to avoid dissecting the PA away, which could damage it. Antegrade cardioplegia was performed.
The 10 cm right atrium was then opened. The tricuspid ring was found to be excessively large and was removed. Then, the iatrogenic ASD was found; it was large and located near the mitral valve, so it was opened to approach the mitral valve. The large hole resulting from the torn annuloplasty ring was seen and removed, and because the patient was 88-years-old, Dr. Gaudiani decided to replace the mitral valve, using the previous ring to gain exposure for the sutures. The anterior leaflet was excised while the posterior leaflet was preserved, and a 33 mm valve was used, featuring short struts and a flexible sewing ring.
After the mitral valve was replaced, the atrial septal defect was closed simply by oversewing the large defect with two layers of sutures. Finally, the enlarged tricuspid annulus was corrected by downsizing to a 33 mm tricuspid valve replacement, and a leadless pacemaker was implanted prior to valve replacement. The patient was then closed and decannulated, and made an excellent recovery.
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