ABSTRACT
Background: Mitral valve repair (MVR) represents the gold standard for severe regurgitation in degenerative mitral valve disease. Trans-ventricular beating heart off- pump MVR is a micro-invasive surgical technique to treat mitral valve prolapse, which does not require cardiopulmonary bypass, nor cardioplegic arrest or sternotomy. Indications, however, have to date been restricted to elective cases. We report the first patient emergently treated with this technique. Clinical Case: A 64-year-old man presented to the emergency department with dyspnoea, chest pain and pulmonary edema. Echocardiography showed severe mitral regurgitation caused by acute posterior leaflet chordal ruptures. Ejection fraction was 60%. The patient rapidly developed cardiogenic shock requiring mechanical ventilation. Decision-making: Refractory heart failure mandated emergent MVR. In view of the chest radiograph and the suspicion of COVID-19 (swab not yet available), the micro- invasive beating heart approach was considered with the aim to reduce inflammatory response and lung injury related to cardiopulmonary bypass. Feasibility was confirmed by transesophageal echocardiography, which showed a P2 flail and good predicted coaptation. Three polytetrafluoroethylene neochords were attached to the free edge of the prolapsing P2 segment through a left minithoracotomy. Skin-to-skin duration of the operation was 80 minutes. Residual regurgitation was less than mild. The patient was soon discharged home. The two months follow-up confirmed a good result of the valvuloplasty. Conclusion: This case demonstrates the safety and efficacy of the beating heart off- pump MVR, even in emergent situation. Considering the current pandemic situation, with overwhelmed health care systems, the possibility to shorten and unburden the patient's in-hospital stay with micro-invasive procedures should be routinely considered.