Case Report: Minimal Access Mitral Valve Replacement in a 46-Year-Old Female with Mitral Stenosis

This case report describes the first minimal access mitral valve replacement (MAMVR) performed at Sterling Hospital on a 46-year-old female patient diagnosed with severe mitral stenosis. The patient exhibited significant symptoms, leading to surgical intervention. This report discusses the preoperative assessment, surgical procedure, postoperative care, and follow-up outcomes.

Introduction

Mitral stenosis, a common valvular heart disease often resulting from rheumatic fever, can lead to significant morbidity and mortality if untreated. This case presents a novel approach to mitral valve replacement through minimal access techniques, which offer potential benefits such as reduced pain, shorter recovery times, and improved cosmetic outcomes.

Patient Presentation

A 46-year-old female presented with complaints of progressive breathlessness classified as New York Heart Association (NYHA) functional class III. She reported increasing difficulty in performing daily activities, accompanied by orthopnea and paroxysmal nocturnal dyspnea. 

Medical History

The patient had a history of rheumatic heart disease diagnosed in her youth. She reported no other significant medical history, was not on anticoagulation therapy, and had no history of smoking or alcohol abuse. Family history was non-contributory.

Examination and Investigations

On physical examination, the patient was found to have a weak, irregular pulse and a loud S1 heart sound. Auscultation revealed a diastolic murmur indicative of mitral stenosis. An echocardiogram revealed a mitral valve area of 0.6 cm², left atrial enlargement, and pulmonary hypertension. Other laboratory tests, including complete blood count and renal function tests, were within normal limits.

Preoperative Assessment

The patient underwent a comprehensive preoperative assessment including a chest X-Ray and a detailed echocardiogram. A multidisciplinary team, including cardiologists and anesthesiologists, evaluated the patient's fitness for surgery. Due to her symptoms and the severely reduced mitral valve area, the decision was made to proceed with MAMVR.

Surgical Procedure

The surgery was performed under general anesthesia. The minimal access approach utilized a left thoracotomy incision, measuring only 7 cm at the 4th intercostal space. Femoro- femoral cardiopulmonary bypass (CPB) was established, and the mitral valve was excised.

A mechanical prosthetic valve was implanted, and thorough de-airing of the left atrium was conducted to prevent postoperative comp-lications. The surgical time was approximately 180 minutes. Hemostasis was achieved, and the chest was closed in layers.

Postoperative Care

The patient was transferred to the ICU for close monitoring. She remained intubated for a few hours post-surgery but was extubated within 6 hours. Initial management in the ICU included inotropic support, diuretics, and anticoagulation therapy as per protocol.

On postoperative day 2, the patient was stable and transferred to the general ward. She was able to mobilize with assistance and exhibited marked improvement in symptoms. She was discharged on postoperative day 5 with stable hemodynamics and improved exercise tolerance. 

Follow-Up

The patient attended follow-up appointments at 1 week, 1 month, and 3 months post-surgery. Clinical examinations demonstrated normal heart sounds with no murmurs, and echocardiographic evaluations confirmed satisfactory function of the prosthetic valve. The patient reported significant improvement in her exercise capacity and overall quality of life, achieving NYHA class I.

Discussion

Mitral stenosis can significantly impair quality of life due to debilitating symptoms. MAMVR represents a valuable surgical option, particularly in selected patients with suitable anatomy and disease severity. The minimal access technique not only facilitates a shorter recovery time but also offers a favorable cosmetic outcome, which may improve patient satisfaction.

This case demonstrates that MAMVR can be safely performed with excellent outcomes. Early postoperative recovery was swift, with only a 2-day ICU stay and discharge on the 5th postoperative day. The follow-up results underscore the effectiveness of this approach, showcasing the patient's return to normal activities and symptom relief.

Conclusion

This case illustrates the successful implementation of minimal access mitral valve replacement in a patient with severe mitral stenosis, marking a significant milestone for Sterling Hospital. As minimally invasive techniques continue to evolve, they will likely play an increasingly important role in the management of valvular heart disease, leading to enhanced patient outcomes and satisfaction.