A frail 82-year-old woman was referred to our clinic with shortness of breath and palpitations. Her echocardiogram demonstrated left ventricular ejection fraction of 65%, severe aortic valve regurgitation, mild to moderate functional mitral valve regurgitation (Carpentier type IIIb mechanism, effective regurgitant orifice area [EROA] 0.1 cm2, regurgitant volume [RV] 13 mL, color area of MR 6.3 cm2, mitral annulus 27 mm, Fig. 1, Additional file 1: Video S1), and increased systolic pulmonary artery pressures 50 mmHg. In consideration of her frail condition and our expectation of difficult mitral valve exposure due to her very bent back, aortic valve replacement (Mitroflow 21 mm) without mitral surgery was performed. The aortic cross-clamp time was 92 min. The transesophageal echocardiogram revealed left ventricular ejection fraction of 55% and severe functional mitral regurgitation caused by left ventricular dilatation on weaning from cardiopulmonary bypass. The etiology of MR was identified as asymmetric posterior leaflet tethering (Carpentier type IIIb mechanism, EROA 0.2 cm2, RV 29 mL, color area of MR 11.3 cm2, mitral annulus 32 mm, Fig. 2, Additional file 2: Video S2), a result of temporary left ventricular dysfunction. She had hemodynamic instability and difficulty to wean off cardiopulmonary bypass.
Additional file 1: Video S1. Preopertative transesophageal echocardiography images showing mitral valve and a color Doppler image showing mild to moderate functional mitral regurgitation. (MP4 1044 kb)
Additional file 2: Video S2. Intraoperative transesophageal echocardiography images after aortic valve surgery, showing a color Doppler image showing severe functional mitral regurgitation caused by left ventricular dilatation. (MP4 1063 kb)
The aorta was cross clamped again and the heart was arrested. As expected, it is difficult to expose her mitral valve due to her very bent back and after aortic valve replacement. There was no abnormality of the mitral apparatus. A central edge-to-edge Alfieri stitch (mattress 4–0 braided suture) was placed between the anatomical middle of the two leaflets of the mitral valve. The second aortic cross-clamp time was 46 min.
Transesophageal echocardiogram demonstrated mild mitral regurgitation (Carpentier type IIIb mechanism, EROA 0.1 cm2, RV 10 mL, color area of MR 4.3 cm2, mitral annulus 32 mm, Fig. 3, Additional file 3: Video S3). The patient was then successfully weaned from cardiopulmonary bypass. The patient made an uneventful recovery and was discharged home on post-operative day 14.
Additional file 3: Video S3. Intraoperative transesophageal echocardiography images after alieri stitch was performed, showing a color Doppler image showing mild to moderate residual mitral regurgitation. (MP4 1050 kb)