On-Pump Beating-Heart Redo Mitral Valve Surgery

BACKGROUND: Severe mechanical hemolysis following the use of a paravalvular leak occluder plug is a challenging complication, particularly for patients with multiple comorbidities who face prohibitive risks with repeat surgery. CASE SUMMARY: A 63-year-old multimorbid man with end-stage renal disease presented with severe microangiopathic hemolytic anemia after transcatheter paravalvular leak closure. Ten months earlier, he had undergone aortic and mitral valve replacements and coronary bypass, complicated by a difficult recovery requiring temporary mechanical circulatory support with an Impella. Now, to minimize the operative risk and avoid the difficult postoperative course experienced after the previous surgery requiring mechanical circulatory support, a modified, infrequent surgical strategy was used: On-pump, beating-heart redo mitral valve replacement with extraction of the occluder plug. It successfully circumvented global myocardial ischemia and simplified complex redo surgery. Postoperatively, the hematologic parameters normalized within days. DISCUSSION: This personalized, risk-adapted surgical strategy mitigates operative risk in a high-risk patient, achieving rapid, definitive resolution of hemolytic anemia. TAKE-HOME MESSAGES: Eliminating the source of mechanical hemolysis results in rapid normalization of laboratory parameters within days. On-pump beating-heart surgery is a valuable strategy to simplify complex redo procedures while minimizing high perioperative risk.