Surgical Technique:
Under general anesthesia, two incisions; median sternotomy and right groin for arterial cannulation were made. Porcelain aorta was confirmed. Right femoral arterial and bicaval cannulae were indwelled. Cardiopulmonary bypass (CPB) was performed. The mean arterial pressure was maintained between 65 and 80 mmHg. The aorta was not cross-clamped, no cardioplegia was used during the procedure, and the heart was allowed to beat. To prevent any possible air embolism, the patient was kept in the Trendelenburg position throughout the procedure. Patient was cooled down to 280C to control heart racing .MV approached directly through the left atrium (LA), access very difficult, due to abnormal annulus (facing upward rather than upward and laterally to the right), the MV was found very thickened and myxomatous, as a result, it was replaced using size 25mm mechanical prosthesis with preserving the basal chordate of the posterior mitral leaflet. No obvious leak (on a beating heart). LA was closed in a single layer using 4/0 Prolene. The right atrium (RA) was entered directly and the TV was repaired using the De Vaga technique, however, minimal TR. RA was closed in one layer with 4/0 Prolene. De-airing maneuvers were performed prior to the cessation of CPB. Easy off bypass on Milrinone. The total CPB time was 90 minutes.
Two ventricular pacing wires and two mediastinal drains were left in. Sternum is closed using routine figure of 8 wire closure.