21720478 Visualization

In February Date 2010 Date , a 77 Age - year Age - old Age man Sex with a history of stroke Disease_disorder and peripheral Disease_disorder vascular Disease_disorder disease Disease_disorder presented Clinical_event at our emergency Nonbiological_location department Nonbiological_location in florid Detailed_description pulmonary Disease_disorder edema Disease_disorder .
He had a 6 Duration - month Duration history Duration of worsening History dyspnea History on History exertion Activity , paroxysmal Detailed_description nocturnal Detailed_description dyspnea History , and leg Biological_structure edema History .
Upon physical Diagnostic_procedure examination Diagnostic_procedure , he had diffuse Detailed_description rales Sign_symptom and a murmur Sign_symptom of Sign_symptom aortic Sign_symptom stenosis Sign_symptom .
A 2 Detailed_description - dimensional Detailed_description Doppler Detailed_description transthoracic Biological_structure echocardiogram Diagnostic_procedure revealed severe Severity aortic Disease_disorder valve Disease_disorder stenosis Disease_disorder with a peak Diagnostic_procedure gradient Diagnostic_procedure of 70 Lab_value mmHg Lab_value and a mean Diagnostic_procedure gradient Diagnostic_procedure of 45 Lab_value mmHg Lab_value , a calculated Diagnostic_procedure aortic Diagnostic_procedure valve Diagnostic_procedure area Diagnostic_procedure of 0.7 Lab_value cm2 Lab_value , severe Severity mitral Disease_disorder regurgitation Disease_disorder , and a severely Severity dilated Sign_symptom left Biological_structure ventricle Biological_structure ( LV Biological_structure ) with an ejection Diagnostic_procedure fraction Diagnostic_procedure of 0.20 Lab_value .
After the pulmonary Disease_disorder edema Disease_disorder had resolved, cardiac Diagnostic_procedure catheterization Diagnostic_procedure confirmed the echocardiographic Coreference findings Coreference and showed nonobstructive Detailed_description coronary Disease_disorder artery Disease_disorder disease Disease_disorder .
Given these findings and the patient's comorbidities, we decided on a minimally Detailed_description invasive Detailed_description surgical Therapeutic_procedure approach Therapeutic_procedure .
The patient was placed in the supine Therapeutic_procedure position Therapeutic_procedure and underwent anesthetic Medication induction and intubation Therapeutic_procedure with a single Detailed_description - lumen Detailed_description endotracheal Detailed_description tube Detailed_description and a bronchial Detailed_description blocker Detailed_description .
Intraoperative transesophageal Diagnostic_procedure echocardiography Diagnostic_procedure ( TEE Diagnostic_procedure ) confirmed the previous findings, also showing that the mitral Biological_structure valve Biological_structure leaflets Biological_structure were free of significant Disease_disorder disease Disease_disorder and that the mitral Disease_disorder regurgitation Disease_disorder originated in the A2 Biological_structure – P2 Biological_structure portion Biological_structure of the mitral Biological_structure valve Biological_structure (Fig.1).
The mitral Disease_disorder regurgitation Disease_disorder was thought to be functional Detailed_description , caused by mitral Sign_symptom annular Sign_symptom dilation Sign_symptom and tethering Sign_symptom of the papillary Biological_structure muscles Biological_structure by the severely Severity dilated Sign_symptom LV Biological_structure .
We decided to perform edge Detailed_description - to Detailed_description - edge Detailed_description repair Therapeutic_procedure of the mitral Biological_structure valve Biological_structure from a transaortic Detailed_description approach Detailed_description .
A femoral Therapeutic_procedure platform Therapeutic_procedure was used to establish cardiopulmonary Therapeutic_procedure bypass Therapeutic_procedure .
A 2- to Distance 3 Distance - cm Distance incision Therapeutic_procedure was made in the left Biological_structure inguinal Biological_structure crease Biological_structure .
A 5–0 Prolene Detailed_description purse Detailed_description - string Detailed_description suture Therapeutic_procedure ( Ethicon Detailed_description Inc., Detailed_description a Detailed_description Johnson Detailed_description & Detailed_description Johnson Detailed_description company; Detailed_description Somerville, Detailed_description NJ Detailed_description ) was placed in the femoral Biological_structure artery Biological_structure and Biological_structure vein Biological_structure .
The left Biological_structure femoral Biological_structure artery Biological_structure was cannulated Therapeutic_procedure with a 16F–18F arterial Detailed_description cannula Detailed_description .
The left Biological_structure femoral Biological_structure vein Biological_structure was cannulated Therapeutic_procedure with a 25F Detailed_description Bio Detailed_description - Medicus® Detailed_description femoral Detailed_description venous Detailed_description cannula Detailed_description ( Medtronic, Detailed_description Inc.; Detailed_description Minneapolis, Detailed_description Minn Detailed_description ), which was placed in the superior Biological_structure vena Biological_structure cava Biological_structure with the aid of TEE Diagnostic_procedure .
We then made a 4- to Distance 5 Distance - cm Distance transverse Detailed_description parasternal Detailed_description incision Therapeutic_procedure over the 3rd Biological_structure intercostal Biological_structure space Biological_structure and transected the 4th Biological_structure costochondral Biological_structure cartilage Biological_structure to enable adequate exposure Therapeutic_procedure of the aorta Biological_structure .
This interspace was chosen in the event that the left atrium needed to be entered.
The pericardium Biological_structure was opened Therapeutic_procedure above Biological_structure the Biological_structure phrenic Biological_structure nerve Biological_structure and over Biological_structure the Biological_structure aorta Biological_structure to facilitate exposure Therapeutic_procedure .
A retrograde Detailed_description coronary Biological_structure sinus Biological_structure catheter Therapeutic_procedure was inserted directly through the incision Therapeutic_procedure , and a purse Detailed_description - string Detailed_description suture Therapeutic_procedure was placed in the right Biological_structure atrium Biological_structure .
A LV Biological_structure vent Therapeutic_procedure was inserted via a purse Detailed_description - string Detailed_description suture Therapeutic_procedure in the right Biological_structure superior Biological_structure pulmonary Biological_structure vein Biological_structure .
A transverse Detailed_description aortotomy Therapeutic_procedure was performed to expose Therapeutic_procedure the aortic Biological_structure valve Biological_structure , which was removed Therapeutic_procedure under direct Diagnostic_procedure vision Diagnostic_procedure .
The A2 Biological_structure and Biological_structure P2 Biological_structure segments Biological_structure of the mitral Biological_structure valve Biological_structure were identified Diagnostic_procedure , and an edge Detailed_description - to Detailed_description - edge Detailed_description repair Therapeutic_procedure was carried out with a 5–0 Prolene Detailed_description mattress Detailed_description suture Therapeutic_procedure that was reinforced Detailed_description with Detailed_description pericardial Detailed_description pledgets Detailed_description on the ventricular Biological_structure side Biological_structure of the mitral Biological_structure valve Biological_structure (Fig.2).
Next, a 27 Detailed_description - mm Detailed_description Hancock® Detailed_description II Detailed_description bioprosthetic Therapeutic_procedure aortic Therapeutic_procedure valve Therapeutic_procedure ( Medtronic Detailed_description ) was implanted Therapeutic_procedure by use of standard Detailed_description techniques Detailed_description .
The aortotomy Therapeutic_procedure was closed Therapeutic_procedure in 2 Detailed_description - layer Detailed_description fashion Detailed_description , and the patient was weaned from cardiopulmonary Therapeutic_procedure bypass Therapeutic_procedure .
The transected rib Biological_structure was reattached Therapeutic_procedure to the sternum Biological_structure with a 1 Detailed_description - cm Detailed_description metal Detailed_description plate Detailed_description ( Synthes, Detailed_description Inc.; Detailed_description West Detailed_description Chester, Detailed_description Pa Detailed_description ), and a fiber Detailed_description wire Detailed_description was placed Therapeutic_procedure in figure-8 fashion Detailed_description .
A single Quantitative_concept chest Detailed_description tube Detailed_description was left Therapeutic_procedure in the pleural Biological_structure space Biological_structure .
The thoracotomy Therapeutic_procedure was closed Therapeutic_procedure in routine Detailed_description fashion Detailed_description .
Postoperative TEE Diagnostic_procedure showed no mitral Disease_disorder regurgitation Disease_disorder (Fig.3); “ elbowing Sign_symptom ” of the anterior Biological_structure leaflet Biological_structure during mid-diastole due to tethering Sign_symptom of the anterior Biological_structure leaflet Biological_structure to the posterior Biological_structure leaflet Biological_structure (Fig.4); and the double Sign_symptom - orifice Sign_symptom mitral Biological_structure valve Biological_structure that resulted from the edge Detailed_description - to Detailed_description - edge Detailed_description repair Therapeutic_procedure (Fig.5).
After surgery Therapeutic_procedure , the patient did Sign_symptom well Sign_symptom .
His shortness Sign_symptom of Sign_symptom breath Sign_symptom resolved, and he was discharged Clinical_event from the hospital Nonbiological_location on postoperative Date day Date 6 Date .
Upon follow Clinical_event - up Clinical_event evaluation in March Date 2011 Date , he was asymptomatic Sign_symptom , and echocardiography Diagnostic_procedure showed grade Lab_value 1+ Lab_value mitral Disease_disorder regurgitation Disease_disorder .