J Extra Corpor Technol 2023 , 55 , 201 – 205 Ó The Author ( s ), published by EDP Sciences , 2023 https :// doi . org / 10.1051 / ject / 2023040
Available online at : ject . edpsciences . org
CASE REPORT
Fifth-time redo mitral valve replacement via right thoracotomy under systemic hyperkalemia cardiopulmonary bypass without aortic cross-clamp
Tomohisa Takeichi ( CCP ) 1 ,* , Yoshihisa Morimoto ( MD ) 2 , Akitoshi Yamada ( MD ) 2 , and Takanori Tanaka ( CCP ) 1
1 Department of Clinical Engineering , Kitaharima Medical Center , 926-250 , Ichiba-cho , Ono-shi , Hyogo 675-1392 , Japan 2 Department of Cardiovascular Surgery , Kitaharima Medical Center , 926-250 , Ichiba-cho , Ono-shi , Hyogo , 675-1392 , Japan
Received 2 March 2023 , Accepted 21 September 2023
Abstract – The surgical management of prosthetic valvular endocarditis ( PVE ) can be challenging . We report a case of a 46-year-old female patient who had a history of four cardiac operations . We chose a mitral valve replacement via right thoracotomy to enable optimal exposure of the mitral valve ( MV ). Because of multi-reoperations , we employed systemic hyperkalemia for cardiac arrest to protect the heart during cardiopulmonary bypass ( CPB ) without aortic cross-clamping . Here , we present a complex operation that performed management of CPB under hyperkalemia and the patient had a good postoperative recovery .
Key words : Cardiopulmonary bypass ( CPB ), Systemic hyperkalemia , Right thoracotomy , Reoperation .
Introduction
Five times of cardiac reoperations for PVE are a complex operation with significant risk . Due to the difficulty of aortic cross-clamping , mitral valve replacement ( MVR ) is performed under beating heart ( BH ) or ventricular fibrillation ( VF ) conditions . On-pump BH or VF valvular operations may have some technical advantages and utilities [ 1 ]. However , some studies have shown that the BH alternative with the VF approach is inferior to the empty heart technique due to its reduction in oxygen delivery to the subendocardium and the consequent suboptimal myocardial protection [ 2 , 3 ]. In this case , we determined that it was difficult to perform MVR via the right thoracotomy procedure under the BH and VF techniques . Because , we had no previous experience with the BH technique in complex reoperation cases and , there was a need to secure a surgical field of view close to cardiac arrest . Moreover , though the VF condition was not an inappropriate myocardial protection strategy [ 4 ], in this case , the prolonged operative time was anticipated . The longer the VF time , the more reduction in oxygen delivery to the subendocardium , and the more creatine-kinase MB ( CK-MB ) increases [ 5 , 6 ]. Therefore , in the case of VF , we thought that weaning from CPB was difficult under the prolonged VF time , and we chose the systemic hyperkalemia strategy during CPB to protect the heart .
* Corresponding author : tommo . tommo @ outlook . jp
This study was approved by the Institutional Review Board at Kitaharima Medical Center ( IRB-0443 ) with the waiver of informed consent .
Case report
The patient ( height 156 cm ; weight 41 kg ) had a history of recurrent cardiac operations , starting with a MVR at the age of 31 for infective endocarditis . At the age of 33 , she underwent two further reoperations , including MVR for a stuck valve and patch repair for pseudoaneurysm of the ascending aorta due to mediastinitis . Additionally , an omental wrapping was performed . At the age of 42 , the patient underwent an emergency MVR via right thoracotomy under VF of the stuck valve .
This time , the patient was diagnosed with sepsis and prosthetic valve endocarditis ( PVE ) by transesophageal echocardiography ( TEE ) and positive blood cultures in our clinical microbiology laboratory . Mitral valve and aortic valve regurgitation were not confirmed . A five times MVR via right thoracotomy procedure was planned . We performed systemic hyperkalemia for cardiac arrest during CPB without aortic cross-clamping because of computed tomography ( CT ) scan showed that omental tissue covered from the right atrium to the entire surface of the aorta ( Figures 1 and 2 ).
Following induction of general anesthesia , the patient underwent MVR via a right thoracotomy procedure . CPB was established with a venous cannula 22 / 22Fr ( MICS Cannulae ;
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