Rheumatic Mitral Valve Reconstruction

The patient was a 20-year-old female referred to the heart center for the evaluation of rheumatic heart disease and severe mitral regurgitation. She reported dyspnea on moderate exertion New York Heart Association (NYHA) Class III, as well as palpitations and reduced exercise tolerance, which progressively worsened over a period of three years. Her rheumatic history dated back to childhood. 

A parasternal long-axis view of the transthoracic echocardiogram showed anterior leaflet edge fibrosis with commissural fusion, and the posterior leaflet was restricted. After the induction of anesthesia, a median sternotomy was performed, followed by standard cannulation of the aorta and the superior and inferior vena cava, with the initiation of cardiopulmonary bypass. Antegrade cardioplegia was administered, and access to the mitral valve was achieved through the right atrium and the interatrial septum. 
 
Stages of Operations 

After the induction of anesthesia, a median sternotomy was performed, followed by standard cannulation of the aorta, superior vena cava, and inferior vena cava with connection to a heart-lung machine. Antegrade cardioplegia was used. Access to the mitral valve was achieved through the right atrium and interatrial septum. 

Surgical Technique 

Step 1: Assessment of the mitral valve leaflets was performed. Intraoperative visualization revealed a fibrotically altered posterior leaflet with reduced surface area, commissural fusion, and thickened, shortened chordae. 

Step 2: Commissurotomy was performed on the anterolateral and posteromedial commissures. A semilunar incision was made at the base of the fibrous annulus of the posterior mitral leaflet between the commissures, and secondary chordae were excised. 

Step 3: Augmentation of the posterior leaflet of the mitral valve was performed using glutaraldehyde-treated autologous pericardium with 5-0 Prolene using a continuous overlock suture. 

Step 4: The saline test demonstrated leaflet coaptation with no evidence of regurgitation. 
 
Postoperative echocardiography demonstrated good coaptation of the mitral valve leaflets, with normal excursion and stable leaflet motion. On color Doppler imaging, there was no evidence of residual mitral regurgitation. 

Postoperative Course 

In the postoperative period, the patient was extubated on the same day as the surgery and stayed in the intensive care unit (ICU) for one day. On postoperative day two, she was transferred to the ward and was discharged on the fourth postoperative day.  

Valve-sparing mitral valve reconstruction in rheumatic disease is a technically demanding but highly effective procedure in terms of avoiding lifelong anticoagulation and achieving more favorable hemodynamic parameters. 

References

1. Downey RS, Rankin JS, Wei LM, Badhwar V. Rheumatic Double Valve Repair Using Two Remodeling Annuloplasty Rings. March 2019. doi:10.25373/ctsnet.7808804.
2. Yang T, Meng X. Repair of Rheumatic Mitral Stenosis Using the SCORE Technique. July 2025. doi:10.25373/ctsnet.29448323
3. Mitral Valve Surgery in Patients With Rheumatic Heart Disease: Repair vs. Replacement Guangguo Fu, Zhuoming Zhou, Suiqing Huang, Guangxian Chen,Mengya Liang, Lin Huang and Zhongkai Wu.

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