Case Report:
A 60-year-old lady presented with worsening dyspnoea (NYHA III), 3-pillow orthopnoea and peripheral oedema. Echo showed severe mitral stenosis (MS) and tricuspid regurgitation, moderate aortic regurgitation and a raised pulmonary artery systolic pressure of 50 mmHg with preserved biventricular function. Her past medical history included rheumatic MS, requiring percutaneous valvuloplasty 15 years previously, and persistent atrial fibrillation. Her coronary angiogram showed unobstructed coronary arteries. Her Euroscore II was 8%. She was referred for surgery.
At surgery, a rheumatic mitral valve (MV) with severe MS and almost obliterated chordae were confirmed. The papillary muscles were attached to the valve leaflets and had to be partly excised with the chords in order to make room in the left ventricular outflow tract. The patient received mechanical mitral (27/29 mm OnX) and aortic (21mm OnX, Cryolife) valve replacements, a tricuspid valve annuloplasty ring (28mm MC3, Edwards) and left atrial appendage clip (50 mm, AtriCure).
Cardiopulmonary bypass (CPB) was weaned with milrinone and noradrenaline infusions. Protamine was administered slowly, but the blood pressure dropped and was unresponsive to fluid resuscitation and adrenaline boluses. Vasopressin had no effect and methylene blue was given as a last resort, eventually raising the blood pressure.
Prior to closing the sternum, blood collected at the back of the heart. A small hole was found 2 cm away from the atrioventricular groove. CPB was re-instated and the defect repaired.
The right ventricle (RV) was now dilated and severely impaired with a CVP of 18 mmHg and the patient was difficult to ventilate. Despite good left ventricle contractility, the patient required increasing inotropic support. When cardiogenic shock persisted, intra-aortic balloon pump (IABP) counter-pulsation was commenced with no effect. The patient was placed on central veno-arterial extracorporeal membrane oxygenation (VA-ECMO) with the chest left open and transferred to the intensive care unit.
RV failure with raised CVP and worsening respiratory function persisted. On post-operative day 9, a Protek Duo right ventricular assist device (RVAD; Protek Duo (TandemLife, Pittsburgh, PA)) was inserted percutaneously via right internal jugular venous (IJV) access, with the proximal inflow lumen positioned in the right atrium and the distal outflow lumen positioned in the main pulmonary artery (Fig. 1). An oxygenator was placed in the circuit. VA-ECMO was discontinued, the patient decannulated and the chest was closed.
By day 14 all support was weaned and the RVAD removed. The patient was extubated with no neurological consequences, but developed a ventilator-associated pneumonia and required a tracheostomy for seven days. She was discharged to her local hospital for convalescence and then home. She was well when reviewed as an out-patient 2 and 6 months later.