Coronary artery bypass grafting, alfieri comisurotomy and ring anuloplasty in a patient with mitral valve prolapse and coronary disease

Introduction: Degenerative MR affects 1–2% of the ge-neral population. In older patients, MVP is due to fibro-elastic deficiency, characterized by thin and translucent valvular tissue. Anatomical and functional alterations that typically characterize degenerative MR are leaflet prolapse into the atrium during systole and annular dilatation. According to current guidelines, patients with severe MR who are symptomatic, mitral valve repair is indicated. This is the optimal surgical treatment and has advantages over valve replacement in terms of pe-rioperative mortality, left ventricular function preser-vation and long-term survival. „Edge-to-edge” surgery technique is a complex procedure. A flexible or semi-rigid prosthetic ring is usually invariably implanted to increase the coaptation surface of the leaflets, reduce the stress on the suture and stabilize the repair.

Case presentation: A patient of 72 years old, diagnosed ten years ago with MR due to MVP, who refused surgical intervention, was admitted with signs and symptoms of heart failure, progressed slowly during the last weeks. We have to point out that he did not mention any history of angina. The patient was evalu-ated clinically, 12 lead ECG, chest X-ray, cerebral com-puter tomography (CT) scan, transthoracic (TTE) and transesophageal (TEE) echocardiography, laboratory investigations, and coronary angiography. At clinical examination, an end-systolic murmur was heard in the IVth left intercostal space. ECG revealed atrial fibrillation. Cardiomegaly was found at the chest x-ray examination. 2D TTE showed severe MR due to anterior MVP (A2, A3 ) with posteriorly direction of regurgitant jet, dilatation of annular mitral ring, mild aortic regurgitation, moderate functional tricuspid re-gurgitation, dilated inferior vena cava without inspi-ratory collapse. 2D TEE confirmed the features found at the TTE examination. Carotid Doppler ultrasound revealed atherosclerotic plaques and coronary angio-graphy three vessel disease. Laboratory tests showed dyslipidemia. The patient received medical treatment: angiotensin-converting enzyme, beta blockers, diure-tics, statins and oral anticoagulation. He was scheduled for surgical intervention. The surgical intervention was a complex: repair of the mitral valve using the edge-to-edge (E-to-E) technique: commissural Alfieri (antero-lateral), implantation of a semi-rigid prosthetic ring, tricuspid annuloplasty and coronary artery by-pass grafting: left internal mammary artery sequential mounted on the diagonal artery I and left anterior des-cendent artery segment II, and with inverted sapheno-us venous autograft on the right coronary artery. Evolu-tion after the surgical intervention was good at 1, 3 and 6 months evaluations.

Conclusions: This presentation reveals a case of a pa-tient with severe MR due to MVP, with significant comorbidities: tree coronary vessel disease, permanent atrial fibrillation, dyslipidemia, pulmonary arterial systolic hypertension. Surgical repair was complicated, but the evolution was excellent. TTE and TEE were im-portant tools that identified mitral regurgitation etio-logy in a patient with coronary disease.

ISSN – online: 2734 – 6382
ISSN-L 1220-658X
ISSN – print: 1220-658X
The Romanian Journal of Cardiology is indexed by:
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CODE: 379
CME Credits: 10 (Romanian College of Physicians)