Beating-heart mitral valve replacement assisted by rapid ventricular pacing after Bentall procedure: a case report

BACKGROUND: Beating-heart open mitral valve replacement (MVR) precludes aorta clamping, cardioplegic arrest, and reperfusion injury in cardiac surgery. However, beating-heart MVR still poses the risk of air embolism. The main cause of air embolisms is effective ventricular contraction and stroke. Rapid ventricular pacing (RVP) is commonly used in transcatheter valve implantation to temporarily halt cardiac output. However, its application in open beating-heart surgery has not explored in depth. Recently, we successfully employed RVP to perform MVR on an on-pump beating heart, without cross-clamping, in a patient with mitral valve prolapse developed 5 years after Bentall procedure. CASE PRESENTATION: A 63-year-old female, who underwent simultaneous Bentall and Sun's procedures five years back, was admitted for dyspnea, orthopnea, and palpitations since 20 days. Echocardiography revealed severe mitral valve regurgitation and prolapse. She had a European System for Cardiac Operative Risk Evaluation II of 6.8%. After multidisciplinary consultations, open-heart MVR on beating heart was scheduled. Following induction of anesthesia, a balloon-tipped flotation pacemaker catheter was introduced into the right ventricle. RVP was activated at 180 beats/min during valve resection and de-airing. The mitral valve was replaced by a pericardial bioprosthesis under cardiopulmonary bypass (CPB). Transesophageal echocardiography confirmed the absence of intracardiac air bubbles. The patient was then successfully weaned off CPB and recovered without complications, regaining consciousness 45 min following the operation. She was discharged on the 8th postoperative day, with a New York Heart Association class I. At the 6-month postoperative follow-up visit, the patient showed satisfactory recovery with no complications. CONCLUSIONS: This case demonstrates that beating-heart MVR with RVP, without aortic cross-clamping, can be used as a viable and feasible option in selected patients who are at a high risk of complications secondary to routine CPB and cardioplegia.