Mitral valve repair or replacement on the beating heart

BACKGROUND: Beating heart (off-pump) coronary artery bypass grafting (CABG) techniques have led us to consider the possibility of performing mitral valve repairs and replacements (with or without CABG) on the beating heart. METHODS: If CABG had to be performed in addition to the valve procedure, CABG was done first on the beating heart without cardiopulmonary bypass, if possible. For the valve procedure, the aorta was cross-clamped and the beating-heart status was maintained throughout the whole procedure with continuous, warm, oxygenated blood coronary-sinus perfusion. RESULTS: We used this technique in 23 patients with extremely low ejection fractions, 78% of whom were in New York Heart Association (NYHA) class 4 and 17% of whom were in New York Heart Association (NYHA) class 3. The procedures were: mitral-tricuspid (11 patients), mitral-aortic (7 patients), mitral-tricuspid CABG (1 patient), and mitral-aortic CABG (4 patients). The total early mortality was 13% (3 of 23 patients). Two were in-hospital deaths. One patient with triple-vessel disease and acute mitral insufficiency (AMI) on intra aortic ballon pump had been operated on six days after AMI. The cause of death was systemic meticillin resistant staphyloccocus aureus infection. (Eight days prior to our operation, arthrodesis of the talocrural joint was performed by an orthopedic surgeon.) The other death was a female patient who was operated on after previous multiple cerebrovascular infarctions (CVIs) (cause of the death was CVI). In addition, one patient died one month after the operation because of prosthetic valve endocarditis on aortic and mitral valves (silver-coated silzone aortic and mitral valves were implanted because of chronic latent asymptomatic tibial osteitis). None of these deaths were cardiac related. CONCLUSIONS: The main advantages of beating heart surgery are: 1) the perfused myocardial muscle, 2) the heart not doing any work, 3) no reperfusion injury, 4) the possibility for ablation of atrial fibrillation on the beating heart, and 5) testing of the mitral valve repair is done in real physiologic conditions in the state of left ventricle beating tonus. The procedure could be the procedure of choice for the valve operation or combined operations in high-risk patients with low ejection fractions.