Brief Case Description

 The patient is a 65  year-old male who presented with symptoms of congestive heart failure (CHF). He  has a past medical history of hypertension, diabetes, hyperlipidemia, and prior  myocardial infarction. Physical examination was remarkable for apical systolic  murmur of mitral regurgitation. He underwent a stress test which revealed  inferior and inferolateral scarring.

Transthoracic echocardiography (TTE), parasternal  long axis and four chamber views, showed systolic restricted motion of both  anterior and posterior mitral leaflets (Type IIIb dysfunction). Doppler  echocardiography showed a central jet with mild to moderate mitral  regurgitation. Quantitative measurement revealed a regurgitant orifice area of  18 mm2 and a regurgitant volume of 27 mL. Pisa radius was calculated at 0.6 cm.  Left ventricular end diastolic diameter was 6.8 cm and left ventricular  ejection fraction was 27%.

A TTE performed one  month earlier in another institution showed severe mitral  valve regurgitation and moderate tricuspid  regurgitation.

 

Cardiac  catheterization showed severe three vessel coronary artery disease: proximal left  anterior descending artery 95% and mid 90% stenosis, proximal left circumflex  80% stenosis with mutiple lesions involving obtuse marginals, proximal right  coronary artery 70% stenosis with mid total occlusion. Pulmonary artery  pressure was 50/22 mmHg. Cardiac output and index were 3.8 L/min and 1.9  L/min/M2 respectively.

 

The patient was  referred for coronary revascularization and reconstructive mitral and tricuspid  valve surgery.

 Operative Procedure

 Intraoperative Transesophageal  Echocardiography (TEE)

Intraoperative  transesophageal echocardiography confirmed the diagnosis of type IIIb mitral valve  dysfunction (mid esophageal long axis and four chamber views). Mid esophageal  long axis view with color Doppler interrogation of the mitral valve showed mild  (2+) regurgitation with a central jet. Left ventricular ejection fraction was  calculated at 18%.

 

Coronary Artery Bypass Grafting  (CABG)

The patient underwent  coronary artery bypass grafting with the left internal mammary artery to the  left anterior descending artery and saphenous vein graft from the aorta to the  second obtuse marginal and posterior descending artery (PDA) branches.

Mitral Valve Analysis

Following the exposure  of the mitral valve, we first confirmed the echocardiographic findings by  observing a tethering of both anterior and posterior mitral leaflets. The mitral  annulus was asymmetrically dilated.

Following  echocardiographic and operative valve analysis, we can summarize the  pathophysiological triad as follows:

 Etiology: Ischemic  mitral valve disease

 Lesions: papillary  muscle displacement with leaflets tethering, and secondary annular deformity

 Dysfunction: Type IIIb

Reconstructive Procedure

The patient  underwent  an undersized remodeling  mitral annuloplasty with the implantation of a size 24 mm Carpentier Edwards  Physio ring. The prosthetic ring was downsized by two sizes. The patient  also underwent a tricuspid remodeling  annuloplasty with a 28 mm Carpentier Edwards Classic ring for type I  dysfunction.
 
Postbypass Transesophageal  Echocardiography

Mid esophageal four chamber view showed the  mitral valve with good leaflet coaptation. Mid esophageal four chamber and long  axis views with color Doppler interrogation showed a competent mitral valve  with no residual regurgitation.

 

The postoperative  course was uneventful and the patient was discharged home on postoperative day  eight.

At 3 years, the  patient was doing well and was in NYHA class I-II. TTE showed a competent  mitral valve with no recurrent mitral regurgitation (parasternal long axis and  four chamber views). The mean transmitral gradient was 3 mmHg. Left ventricular  size has decreased with an end diastolic diameter of 4.9 cm while left  ventricular systolic function has improved with an ejection fraction of 43%.  There was only minimal tricuspid regurgitation.

 

Cardiac  catheterization showed all grafts were patent.