A 16-year-old male presented with shortness of breath and exertional fatigue. He had a history of repeat hospitalization due to acute episodes of suspected pulmonary edema. He had previously undergone repair of an anomalous left coronary artery from the pulmonary artery (ALCAPA) combined with mitral valve annuloplasty during infancy.
Transthoracic and transesophageal echocardiography showed severe mitral stenosis with a mean gradient of 16 mmHg, severe left atrial dilation, good left ventricular function, right ventricular hypertrophy, and pulmonary hypertension. Further analysis of the mitral valve showed a good mobile anterior leaflet and a very restrictive orifice. Discussions regarding mitral valve replacement and various options were conducted; however, the patient was not interested in a mechanical prosthesis or anticoagulation at this stage.
After a repeat median sternotomy and the initiation of cardiopulmonary bypass, cardioplegic arrest was achieved with antegrade aortic root cardioplegia. A standard vertical left atriotomy was performed, and the mitral valve was evaluated. The orifice of the valve was quite restrictive, so the surgeons proceeded with the removal of the posterior annuloplasty band, which was quite adherent to the posterior leaflet and restricting its mobility. After removal of the band, the orifice of the mitral valve appeared less restrictive; however, the posterior leaflet itself was short. A fresh autologous pericardial patch was harvested and used to augment the posterior leaflet, thus increasing its height, improving its mobility, and bringing it closer to the anterior leaflet.
The valve was then assessed, and the orifice was sized. Slaine testing revealed only trivial regurgitation. The surgeons were satisfied with this result, considering there was no better alternative at this point. The left atriotomy was closed, and the heart was deaired. The patient was subsequently weaned off cardiopulmonary bypass without difficulty.
The postoperative course was uneventful, and he was discharged four days later. Follow-up echocardiography showed mild mitral stenosis and regurgitation with good left ventricular function. The patient continued to do well and has no symptoms currently.
References
- Brancaccio G, Chinali M, Dionisi S, Trezzi M, Esposito C, Iacobelli R, et al. A Meta-Analysis of Mitral Surgery in Patients Undergoing Surgery for Anomalous Left Coronary Artery: When to Perform Repair? Pediatr Cardiol. 2025 Dec;46(8):2531-2541
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