Heart Valve Disease & Minimally Invasive Surgery | Dr. Wang Chun (Cardiology) | CMCS Shanghai

About Dr. Wang Chun

Dr. Wang Chun is a leading cardiologist at Zhongshan Hospital affiliated with Fudan University, with expertise in structural heart disease and minimally invasive valve repair. He has performed thousands of cardiac procedures and is a key figure in interventional cardiology in China. His work spans both surgical and catheter-based approaches to heart disease, and he serves as Director of the Structural Heart Disease Center at Zhongshan Hospital.

Case Overview

A 74-year-old retired engineer with severe mitral regurgitation due to posterior leaflet prolapse presented with three years of exertional dyspnea and one week of orthopnea. His comorbidity burden — hypertension, type 2 diabetes, COPD, and prior stroke — placed him at high surgical risk (STS PROM 8.5%; EuroSCORE II 12%), making conventional open-chest surgery inadvisable. Catheter-based edge-to-edge repair (TEER) alone was anatomically suboptimal given the wide-base posterior leaflet prolapse and severe annular dilation. Following Heart Team MDT discussion chaired by Dr. Wang Chun, the patient underwent totally thoracoscopic mitral valve repair via three 1.5–2 cm right chest wall ports — with artificial chordae implantation and restrictive annuloplasty ring placement under real-time 3D transesophageal echocardiography (TEE) guidance. Cardiopulmonary bypass time was 85 minutes; blood loss was less than 50 mL. The patient was extubated at 6 hours post-operatively, transferred out of the ICU at 24 hours, and recovered from NYHA Class III to Class I at one month.

Patient Background

• Age / Sex: 74-year-old male
• Occupation: Retired engineer
• Chief Complaint: Exertional chest tightness and dyspnea for 3 years; worsening orthopnea for 1 week
• Medical History: Hypertension (15 years); type 2 diabetes (10 years); chronic obstructive pulmonary disease (COPD); prior ischemic stroke (no residual deficits)

Diagnostic Workup

Transthoracic Echocardiography (TTE)

• Left Atrium: Significantly enlarged (LAD 55 mm)
• Left Ventricle: LVEDD 65 mm
• Mitral Valve: Posterior leaflet prolapse with severe regurgitation (Carpentier Type II); eccentric regurgitant jet
• Ejection Fraction: 55% (preserved)
• Pulmonary Hypertension: Mild (PASP 45 mmHg)

Surgical Risk Stratification

• STS PROM: 8.5% (high surgical risk)
• EuroSCORE II: 12% (high risk)

Clinical Challenge

This patient exemplified the central dilemma in high-risk structural heart disease: the lesion was anatomically ideal for repair, but the patient was not ideal for conventional surgery.

• Surgical perspective: Posterior leaflet prolapse is the most repairable mitral pathology — but conventional median sternotomy with cardiopulmonary bypass carries prohibitive risk in a 74-year-old with COPD, diabetes, and prior stroke. Post-operative respiratory failure and difficult extubation were primary concerns.
• Interventional perspective: Transcatheter edge-to-edge repair (TEER, e.g., MitraClip) offers minimal invasiveness, but the wide-base posterior leaflet prolapse and severe annular dilation created anatomical mismatch risk — incomplete coaptation, iatrogenic mitral stenosis (single orifice converted to double orifice with elevated gradient), and uncertain long-term durability.

Neither conventional surgery nor standalone TEER was the right answer. A hybrid strategy was required.

Heart Team MDT Discussion

Chaired by Dr. Wang Chun (Director, Structural Heart Disease Center, Zhongshan Hospital)
Participating departments: Cardiac Surgery, Interventional Cardiology, Anesthesiology, Echocardiography, Critical Care Medicine.

Dr. Wang Chun's analysis: "For this patient, medical therapy alone cannot improve prognosis. Conventional median sternotomy is using a sledgehammer to crack a nut — the trauma is disproportionate to the benefit. And standalone TEER risks anatomical mismatch and suboptimal long-term outcomes. We need to leverage Zhongshan Hospital's Hybrid OR capability: a hybrid strategy combining minimally invasive surgical repair with intraoperative catheter-based technology as backup."

Final Treatment Plan

• Primary Strategy: Totally thoracoscopic mitral valve repair under real-time 3D TEE guidance
• Access: Three 1.5–2 cm right chest wall ports (no rib division; no sternotomy)
• Cardiopulmonary Bypass: Femoral arteriovenous cannulation (avoiding thoracotomy)
• Repair Strategy: Artificial chordae implantation + restrictive annuloplasty ring placement
• Plan B (Bail-out): If intraoperative exploration revealed repair unfeasible, immediate conversion to TEER implantation via mini-incision-assisted approach

Operative Procedure

Anesthesia & Monitoring

• Double-lumen endotracheal intubation for single-lung ventilation
• Dr. Wang Chun personally placed the TEE probe and established a real-time 3D cardiac model prior to incision

Intraoperative Findings

• Thoracoscopic exploration confirmed: P2 segment posterior leaflet chordae rupture with leaflet prolapse and flail; markedly enlarged left atrium

Key Operative Steps

• Artificial Chordae Implantation: Dr. Wang Chun sutured artificial chordae to the ruptured papillary muscle through the chest wall ports under full thoracoscopic visualization — without direct tactile feedback, relying entirely on 3D TEE and thoracoscopic optics for spatial orientation
• Annuloplasty Ring: Size 30 annuloplasty ring implanted following intraoperative annular measurement
• Saline Test: Real-time TEE confirmed excellent leaflet coaptation, no residual regurgitation, and mean transmitral gradient of only 2 mmHg — confirming repair success and ruling out iatrogenic stenosis

Operative Data

• Cardiopulmonary Bypass Time: 85 minutes (significantly shorter than conventional open repair)
• Estimated Blood Loss: <50 mL
• Plan B: Not required — primary repair successful

Post-operative Recovery (ERAS Protocol)

• 6 Hours Post-op: Endotracheal tube removed — a critical milestone for a COPD patient where prolonged ventilation carries high risk of ventilator-associated pneumonia and respiratory failure
• 24 Hours Post-op: Transferred from ICU to general ward
• Pain Management: Oral analgesics only; VAS pain score <3 — markedly superior to post-sternotomy pain burden

Recovery Timeline

• Post-op Day 7 (Echo): Mitral valve repair morphology excellent; trace residual regurgitation; no stenosis; left atrial diameter beginning to remodel (55 mm → 50 mm)
• Post-op Month 1: NYHA functional class improved from III to I; patient climbing stairs without dyspnea or chest tightness; fully ambulatory

Expert Commentary — Dr. Wang Chun

1. The Value of Technology Integration

As a structural heart disease specialist, I cannot be confined to the identity of either a "surgeon" or an "interventional cardiologist." For patients like this one, minimally invasive surgery provides the anatomical completeness of repair — durability, precise chordal geometry, annular stabilization — while catheter-based technology provides the safety margin: minimal trauma, rapid recovery, and a bail-out option if the primary strategy encounters difficulty. This hybrid model is not a compromise. It is the future of valve disease treatment.

2. Imaging as the Surgeon's Third Eye

Intraoperative TEE is not merely a diagnostic tool in this setting — it is the surgeon's primary sensory interface with the operative field. In totally thoracoscopic surgery, the direct tactile feedback that surgeons rely upon in open procedures is absent. Precise echocardiographic assessment determines artificial chordae length, annuloplasty ring sizing, and the final quality assessment of the repair. The saline test under 3D TEE — confirming coaptation geometry and transmitral gradient in real time — is the moment of truth. Without it, we are operating blind.

3. Patient-Centered Rapid Recovery (ERAS)

For a 74-year-old patient with COPD, the goal is not only long-term survival — it is quality of life from the first post-operative day. The intact chest wall — no divided ribs, no sternotomy — preserved the patient's ability to cough effectively and clear secretions, dramatically reducing pulmonary infection risk. Extubation at 6 hours in a COPD patient is not a routine outcome. It is the direct consequence of every decision made in the operative plan: the approach, the bypass strategy, the anesthetic protocol, and the ERAS pathway. This is what we mean by patient-centered care.

4. Looking Ahead

As transcatheter mitral valve repair (TEER) technology continues to evolve, we may eventually be able to perform complete mitral repair in awake patients via femoral venous access — without cardiopulmonary bypass — even in the highest-risk anatomical scenarios. But today, for patients with anatomy suitable for repair, minimally invasive surgical mitral valve repair remains the gold standard for durability and completeness. The hybrid approach bridges the gap between where we are and where we are going.

How CMCS Shanghai Coordinated This Case

China Medical Concierge Shanghai (CMCS) supported this patient's care pathway from initial overseas inquiry through one-month post-operative follow-up. Our coordination included:

• Pre-arrival echocardiography and cardiac imaging review and specialist referral to Dr. Wang Chun's structural heart disease team at Zhongshan Hospital, Fudan University
• Arrangement of enhanced TTE, 3D TEE pre-operative planning, and surgical risk stratification (STS / EuroSCORE II)
• Bilingual interpretation during Heart Team MDT discussion, including detailed explanation of the hybrid strategy, Plan B bail-out options, and COPD-specific anesthetic and recovery planning
• Surgical admission logistics, including hospital registration, ICU bed coordination, and accommodation support for accompanying family
• On-site medical interpretation throughout the hospitalization, ICU stay, and ERAS recovery period
• Post-discharge coordination of echocardiographic surveillance at 1 week and 1 month, cardiac rehabilitation referral, and ongoing diabetes and hypertension medication management

For international patients facing high-risk structural heart disease — particularly those with multiple comorbidities who have been told they are "too high risk" for conventional surgery — the existence of hybrid minimally invasive options at Shanghai's leading cardiac centers represents a genuine clinical alternative. CMCS exists to connect patients with these capabilities: ensuring every option is evaluated, every risk is explained, and every step of the care pathway is managed from first contact through full recovery.

This case report is de-identified and published for educational purposes. All clinical details have been anonymized in accordance with patient privacy standards. CMCS Shanghai is a medical concierge service and does not provide direct medical care.