Endoscopic Mitral Valve Repair for Barlow’s Disease in a Patient with Severe Pulmonary Dysfunction Post-COVID-19: A Case Report

“>>

How does endoscopic mitral valve repair mitigate surgical trauma and inflammation compared to conventional open-heart surgery, and what specific implications does this have for patients with post-COVID-19 pulmonary dysfunction?

Understanding Barlow’s Disease & Mitral Valve Repair

Barlow’s disease, also known as mitral valve prolapse (MVP) with redundant leaflets, is a common cardiac condition. It often presents with mitral regurgitation – a leakage of blood backward through the mitral valve. Traditionally,surgical mitral valve repair or replacement was the mainstay of treatment for symptomatic patients. However, minimally invasive approaches, specifically endoscopic mitral valve repair, are gaining traction, offering potential benefits like reduced recovery time and smaller incisions. This is particularly relevant in patients with pre-existing conditions that complicate traditional surgery.

The Challenge: Post-COVID-19 pulmonary Complications

The COVID-19 pandemic has left a significant number of individuals with long-term health issues, including severe pulmonary dysfunction. This presents a unique challenge when considering cardiac surgery. The increased risk of pulmonary complications post-surgery, coupled with pre-existing lung damage, necessitates a careful evaluation of surgical options. Traditional open-heart surgery can exacerbate these pulmonary issues, leading to prolonged ventilation and increased morbidity. Post-COVID pulmonary fibrosis and reduced lung capacity are key considerations.

Case Presentation: A 62-Year-Old Female

A 62-year-old female presented with worsening dyspnea (shortness of breath) and fatigue. Her medical history included a confirmed COVID-19 infection six months prior, resulting in documented acute respiratory distress syndrome (ARDS) and persistent pulmonary dysfunction. Echocardiography revealed severe mitral regurgitation secondary to Barlow’s disease. Pulmonary function tests (PFTs) demonstrated a significantly reduced forced vital capacity (FVC) and diffusion capacity for carbon monoxide (DLCO), indicative of severe restrictive lung disease.She was deemed a high-risk candidate for conventional open-heart surgery.

diagnostic Workup

transthoracic Echocardiography (TTE): Confirmed severe mitral regurgitation, leaflet redundancy, and left ventricular enlargement.

Transesophageal Echocardiography (TEE): Provided detailed visualization of the mitral valve anatomy, confirming the suitability for endoscopic repair.

Cardiac MRI: Assessed left ventricular function and ruled out other potential causes of her symptoms.

Pulmonary Function Tests (PFTs): Quantified the severity of her pulmonary dysfunction.

High-Resolution CT Scan of the chest: Revealed evidence of post-COVID pulmonary fibrosis.

Endoscopic Mitral Valve Repair: The Procedure

Given the patient’s pulmonary compromise, we opted for an endoscopic mitral valve repair using a transseptal approach. This technique involves accessing the mitral valve through a small incision in the septum (the wall between the heart’s atria) using an endoscope and specialized instruments.

The key steps included:

1. Transseptal Puncture: A small puncture was created in the interatrial septum under fluoroscopic and echocardiographic guidance.
2. Valve Assessment: The mitral valve was meticulously assessed to determine the optimal repair strategy.
3. Leaflet reconstruction: Using sutures delivered through the endoscope, the prolapsed mitral valve leaflets were reconstructed to restore proper coaptation (closure). artificial chordae tendineae were not required in this case.
4. Regurgitation assessment: intraoperative TEE confirmed the prosperous reduction of mitral regurgitation.
5. Septal Closure: The transseptal puncture was closed using a dedicated device.

postoperative Course & Outcomes

The patient’s postoperative course was remarkably smooth. She required only minimal ventilation support and was extubated within 24 hours. Her length of stay in the intensive care unit (ICU) was significantly shorter compared to what would be expected after conventional surgery.Postoperative echocardiography confirmed successful mitral valve repair with minimal residual regurgitation.

Reduced ICU Stay: 2 days vs. an expected 5-7 days with open surgery.

Shorter Hospitalization: 7 days vs. an expected 10-14 days.

Improved Exercise Tolerance: Demonstrated during cardiac rehabilitation.

Stable Pulmonary function: PFTs showed no significant deterioration postoperatively.

Benefits of Endoscopic Mitral Valve Repair in High-Risk Patients

Minimally invasive cardiac surgery (MICS), particularly endoscopic mitral valve repair, offers several advantages for patients with pre-existing pulmonary dysfunction:

Reduced Trauma: Smaller incisions minimize surgical trauma and inflammation.

Lower Risk of Pulmonary Complications: Less disruption to the chest wall and respiratory mechanics.

Faster Recovery: Shorter hospital stays and quicker return to normal activities.

Improved Pain Control: Reduced postoperative pain.

Preservation of Pulmonary Function: Minimizes the risk of exacerbating pre-existing lung disease.

Considerations & Future Directions

While endoscopic mitral valve repair shows promise, it’s crucial to acknowledge its limitations. Patient selection is paramount.