4-cm surgical incision, simultaneous management of three heart valves and the left atrial appendage

Experiencing exertional dyspnea, frequent fatigue, chest tightness, and palpitations, a 54-year-old female patient presented to University Medical Center Ho Chi Minh City in a state of progressive heart failure. Clinical examination, electrocardiography, and echocardiography revealed that the patient suffered from late-stage multi-valvular heart disease, including severe aortic valve stenosis and regurgitation, severe mitral valve stenosis and regurgitation, and severe tricuspid valve regurgitation. The heart chambers were dilated, and pulmonary arterial pressure was elevated, indicating that the heart had undergone prolonged volume overload.

The patient also had chronic atrial fibrillation, which increased the risk of thrombus formation in the left atrial appendage. Following a comprehensive consultation and evaluation, the surgical team from the Department of Cardiovascular Surgery indicated a minimally invasive thoracoscopic procedure to simultaneously address multiple lesions in a single operation. Through a small incision of approximately 4 cm, the surgeons performed a mechanical aortic valve replacement, a mechanical mitral valve replacement, tricuspid valve repair, and left atrial appendage closure.

According to PhD. Dr. Phạm Trần Việt Chương from the Department of Cardiovascular Surgery at University Medical Center Ho Chi Minh City, multi-valvular heart disease is a condition where two or more heart valves are damaged, causing stenosis, regurgitation, or mixed lesions. When multiple valves are affected, blood flow through the heart is obstructed or regurgitated at multiple sites, forcing the heart to work harder to maintain circulation. Over time, the heart chambers may dilate, intracardiac pressure increases, and the myocardium gradually weakens, causing symptoms such as dyspnea, exertional fatigue, palpitations, chest tightness, and decreased exercise tolerance.

"Multi-valvular heart disease is typically more complex than single-valve lesions because multiple abnormalities occurring simultaneously alter blood flow and increase the burden on the heart. If not evaluated and treated promptly, the disease can progress to severe heart failure, pulmonary hypertension, arrhythmias, and numerous long-term complications," stated PhD. Dr. Phạm Trần Việt Chương.

In this case, intervening during a single operation helps simultaneously resolve the heart valve lesions contributing to heart failure. Aortic and mitral valve replacements help restore more efficient blood flow through the heart. Tricuspid valve repair helps reduce regurgitation and limits volume overload on the right heart. Left atrial appendage closure is performed concurrently to eliminate the site where thrombi commonly form in patients with chronic atrial fibrillation, thereby helping to reduce the risk of thromboembolism.

Within the surgical field accessed through an incision of only about 4 cm, the surgeon must operate with precision on three heart valves located in different anatomical positions while also accessing and closing the left atrial appendage. This is a major challenge due to the restricted operating space, whereas each lesion site requires a specific surgical technique while ensuring the functional efficacy of the entire valve system after circulation is restored.

To ensure safety, the surgical team developed a detailed surgical plan, selected a logical sequence for addressing each lesion, and maintained close multidisciplinary coordination before, during, and after the operation. In addition to the requirement for high precision, the surgeon must also control the cardiopulmonary bypass time and aortic cross-clamp time, as these factors are crucial for myocardial recovery and treatment outcomes.

According to the doctors, minimally invasive thoracoscopic surgery on multiple heart valves requires experienced surgeons with precise manipulation skills in a narrow space and the ability to handle various situations flexibly. When patients are appropriately selected and the surgery is performed at a facility with full professional capabilities, this method offers numerous advantages over traditional open surgery, such as minimizing chest wall trauma, reducing blood transfusion requirements, decreasing postoperative pain, shortening recovery time, and ensuring aesthetic appeal through a small incision.

Following surgery, the patient recovered favorably, with a marked improvement in dyspnea and fatigue. Thanks to the small incision and limited chest wall trauma, the patient experienced minimal pain, mobilized early, and resumed basic activities. Postoperative echocardiography revealed that the mechanical aortic and mitral valves were functioning well with no paravalvular leak, tricuspid regurgitation had decreased to mild, cardiac contractility was good, and pulmonary arterial pressure had decreased. The recovery process was uneventful with no significant complications, and the patient stabilized and was discharged for regular follow-up.

Doctors note that following mechanical heart valve replacement, patients must take oral anticoagulants for life and undergo regular blood tests to maintain blood clotting parameters within the target range. Patients must not arbitrarily stop medication, change dosages, or take additional medications or functional foods without consulting a doctor, as this may increase the risk of thrombus formation leading to valve thrombosis or hemorrhage.

The public should not dismiss symptoms such as exertional dyspnea, unusual fatigue, palpitations, chest tightness, lower extremity edema, or decreased exercise tolerance. These may be signs of progressing valvular heart disease and require timely specialized cardiovascular evaluation. Early detection, selecting the appropriate timing for intervention, and adhering to postoperative monitoring are crucial for improving cardiac function, limiting complications, and helping patients return to their daily lives sooner.