Tricky mitral insufficiency during heart beating surgery

Abstract

Hemodynamic management during beating heart surgery can be challenging. Blood pressure variations can be caused by many different phenomena more or less common. This report describes a patient in whom hemodynamic became extremely unstable because of the sudden and massive aggravation of a pre-existing moderate mitral regurgitation. On the other hand, strong heart displacement appeared to temporally treat this pre-existing leak and to improve cardiac function. These uncommon events could be attached to trivial anatomic specificities. A 78-year-old man with a history of worsening angina was scheduled for coronary artery bypass graft surgery. Coronary angiography revealed critical stenosis in the origin of the left main coronary artery. Other active medical problems included obesity, type 2 Diabetes mellitus, atherosclerosis and obstructive sleep apnoea syndrome. He was deemed unsuitable for endovascular revascularization and was referred for surgery. Because of the presence of aortic calcifications, off-pump surgery was preferred. The preoperative echocardiogram showed a preserved left ventricular ejection fraction (LVEF 55%) and a moderate mitral regurgitation (MR) (grade II/IV). The mechanism of MR was typically ischemic with a slightly enlarged annulus (anterior leaflet/annulus ≥1.3) combined with an increased tethering of the posterior leaflet. The jet was central and its proximal width was 0.35 cm. It reached the middle of the left atrium and its surface area was 37 mm (Fig. 1). The patient was induced with a target-controlled infusion of remifentanil in association with midazolam, propofol and cis-