Heart Valve Surgery | Prof. Mei Ju (Cardiac Surgery) | CMCS Shanghai

About Prof. Mei Ju

Prof. Mei Ju is a senior cardiac surgeon at Ruijin Hospital, Shanghai Jiao Tong University School of Medicine — one of China's foremost centres for cardiac surgery, valve repair and replacement, coronary revascularisation, and complex congenital heart disease correction. He specialises in valve repair and replacement, coronary artery bypass grafting (CABG), and the surgical correction of complex congenital cardiac anomalies, with particular expertise in minimally invasive cardiac procedures and combined operations addressing multiple cardiac pathologies in a single surgical setting. Prof. Mei's clinical philosophy holds that patients with multiple concurrent cardiac lesions — valve disease, coronary artery disease, and congenital defects — are best served by a comprehensive surgical strategy that addresses all pathologies simultaneously, avoiding the cumulative risk of staged procedures and delivering a single, definitive correction of the patient's complete cardiac anatomy. His department at Ruijin Hospital has established one of Shanghai's most experienced programmes for complex combined cardiac surgery, with a dedicated team whose outcomes in valve repair, coronary revascularisation, and congenital heart disease correction are recognised as among the most advanced in China.

Case Overview

A middle-aged Chinese man presented with recurrent chest tightness and palpitations. Detailed cardiac workup revealed three concurrent cardiac pathologies: severe mitral regurgitation due to mitral valve prolapse, causing significant haemodynamic burden through left ventricular-to-left atrial regurgitation; multi-vessel coronary artery disease with severe stenosis compromising myocardial blood supply; and an atrial septal defect (ASD) creating an abnormal interatrial communication with adverse haemodynamic consequences. Following multidisciplinary team (MDT) discussion involving cardiac surgery, cardiology, anaesthesia, and radiology, the team formulated a combined surgical strategy to address all three pathologies simultaneously: mitral valve repair, coronary artery bypass grafting using the patient's own saphenous vein, and ASD patch closure. The procedure was completed in approximately 6 hours with well-controlled intraoperative blood loss. The patient was transferred to the ICU postoperatively, returned to the general ward on day 10, and was discharged in good condition on postoperative day 15 — with no major complications and progressive normalisation of cardiac function.

Patient Background

• Name / Nationality: Mr. [Pseudonym] — Chinese male, middle-aged
• Chief Complaint: Recurrent chest tightness and palpitations
• Cardiac pathologies identified:
  • Mitral valve disease: Mitral valve prolapse with severe mitral regurgitation — systolic regurgitation of blood from the left ventricle to the left atrium, increasing cardiac workload and reducing forward cardiac output
  • Coronary artery disease: Multi-vessel severe coronary stenosis compromising myocardial perfusion — contributing to symptoms of chest tightness and reduced exercise tolerance
  • Congenital heart disease: Atrial septal defect (ASD) — abnormal interatrial communication causing left-to-right shunting, volume overload of the right heart, and adverse haemodynamic consequences
• Cardiac function: Impaired — reduced exercise tolerance; chest tightness and palpitations on minimal exertion; cardiac function assessed as compromised on echocardiographic and clinical evaluation
• Surgical risk: Elevated — three concurrent cardiac pathologies requiring combined surgical correction; prolonged cardiopulmonary bypass anticipated; complexity of simultaneous valve repair, coronary revascularisation, and septal defect closure

Diagnostic Workup

Imaging

• Transthoracic and transoesophageal echocardiography: Mitral valve prolapse confirmed; severe mitral regurgitation quantified; left ventricular dimensions and systolic function assessed; ASD size and location characterised; interatrial shunt direction and magnitude assessed; right heart dimensions and function evaluated
• Coronary CT angiography (CTA): Multi-vessel severe coronary stenosis confirmed; coronary anatomy mapped; target vessels for bypass grafting identified
• Cardiac MRI: ASD size and position further characterised; myocardial viability and perfusion assessed; cardiac chamber dimensions and function quantified

Functional Assessment

• Exercise tolerance: Significantly reduced — symptoms on minimal exertion; New York Heart Association (NYHA) functional class assessed
• Cardiac biomarkers: Assessed as part of preoperative risk stratification
• Pulmonary function: Assessed in the context of right heart volume overload from ASD shunting

Multidisciplinary Team (MDT) Assessment

• MDT discussion: Cardiac surgery, cardiology, anaesthesia, and radiology; comprehensive assessment of all three cardiac pathologies and their haemodynamic interactions; decision to proceed with simultaneous mitral valve repair, CABG, and ASD closure confirmed; individualised surgical and perioperative management plan formulated

Prof. Mei's pre-operative assessment: This patient presents us with three concurrent cardiac pathologies, each of which would independently warrant surgical correction. The question is not whether to operate, but how to address all three problems most safely and effectively. A staged approach — correcting one lesion at a time — would expose the patient to the cumulative risk of multiple anaesthetics and cardiopulmonary bypass runs, and would leave the haemodynamic burden of the uncorrected lesions in place during the recovery from each staged procedure. A combined approach — correcting all three pathologies in a single operation — carries a higher immediate operative complexity but delivers a definitive correction of the patient's complete cardiac anatomy in one setting, with a single recovery. For a patient of this age and functional status, with three correctable lesions and no contraindications to combined surgery, the combined approach is the right strategy. The key is meticulous surgical planning, precise intraoperative technique, and the full support of the multidisciplinary team.

Treatment Strategy: Simultaneous Mitral Valve Repair, Coronary Artery Bypass Grafting, and Atrial Septal Defect Closure

The diagnosis was Concurrent Mitral Valve Prolapse with Severe Regurgitation, Multi-Vessel Coronary Artery Disease, and Atrial Septal Defect in a middle-aged patient with impaired cardiac function and reduced exercise tolerance.

The treatment principle was: simultaneous surgical correction of all three cardiac pathologies in a single combined operation — mitral valve repair to restore competent valve function, coronary artery bypass grafting to revascularise the ischaemic myocardium, and ASD patch closure to eliminate the interatrial shunt — achieving comprehensive cardiac correction with a single cardiopulmonary bypass run and a single recovery.

Procedure — Combined Cardiac Surgery:

• Mitral valve repair: Meticulous dissection and assessment of the mitral valve leaflets and chordae tendineae; repair of the prolapsed leaflet — techniques including leaflet resection, chordal transfer, or artificial chordae implantation as required by the anatomy; annuloplasty ring implantation to restore annular geometry and ensure durable valve competence; intraoperative transoesophageal echocardiography to confirm repair quality and absence of residual regurgitation before chest closure
• Coronary artery bypass grafting (CABG): Harvest of the patient's own great saphenous vein as conduit; construction of bypass grafts from the aorta to the coronary arteries distal to the stenotic segments — restoring myocardial blood supply beyond the obstructions; graft patency confirmed intraoperatively
• Atrial septal defect (ASD) closure: Direct visualisation of the ASD through the right atrium; patch closure of the defect using pericardial or synthetic patch material — eliminating the interatrial communication and restoring normal cardiac haemodynamics; absence of residual shunt confirmed by intraoperative echocardiography
• Total operative time: Approximately 6 hours; intraoperative blood loss well controlled; cardiopulmonary bypass and myocardial protection managed by the anaesthetic and perfusion team

Treatment Course and Outcomes

Intraoperative

• Combined mitral valve repair, CABG, and ASD closure completed successfully under Prof. Mei Ju's guidance; mitral valve repair confirmed competent on intraoperative echocardiography; bypass graft patency confirmed; ASD closure confirmed with no residual shunt; intraoperative blood loss well controlled; no major intraoperative complications

Postoperative ICU Course (Days 1–10)

• Patient transferred to the ICU immediately postoperatively for intensive monitoring; individualised recovery protocol implemented — vital sign monitoring, infection prevention, nutritional support, and early functional rehabilitation; cardiac function monitored closely with progressive improvement
• No major postoperative complications — no haemorrhage, no low cardiac output syndrome, no arrhythmia requiring intervention, no wound infection

General Ward and Discharge (Days 10–15)

• Patient transferred to the general ward on postoperative day 10; diet and mobility progressively restored; cardiac function continuing to improve
• Comprehensive assessment on postoperative day 15 confirmed good overall condition; discharge criteria met; patient discharged in good condition on day 15

Prof. Mei's clinical reflection: The outcome of this case — successful repair of the mitral valve, complete coronary revascularisation, and closure of the atrial septal defect in a single operation, with no major complications and discharge on day 15 — demonstrates what is achievable when surgical planning is comprehensive, intraoperative technique is precise, and the multidisciplinary team functions as a unit. The mitral valve repair is the most technically demanding component: the goal is not simply to eliminate regurgitation but to restore the valve's natural geometry and durability — a repair that will last the patient's lifetime without the anticoagulation burden of a prosthetic valve. The intraoperative echocardiography is our quality control: we do not close the chest until the echo confirms that the repair is competent and durable. The CABG and ASD closure are technically straightforward in experienced hands, but their combination with the valve repair in a single operation requires careful sequencing and precise management of cardiopulmonary bypass time. The result — a patient whose three cardiac problems are all corrected in a single recovery — is the best outcome we can offer, and this case demonstrates that it is achievable.

Expert Commentary — Prof. Mei Ju

1. Mitral Valve Repair: Surgical Principles, Techniques, and the Case for Repair Over Replacement

Mitral valve repair — the reconstruction of the native mitral valve to restore competent function without prosthetic replacement — is the preferred surgical treatment for mitral regurgitation due to valve prolapse in patients who are candidates for repair, and is associated with superior long-term outcomes compared with mitral valve replacement in terms of survival, preservation of left ventricular function, freedom from reoperation, and avoidance of the anticoagulation burden and thromboembolic risk associated with mechanical prostheses. The surgical principles of mitral valve repair are: accurate anatomical diagnosis of the mechanism of regurgitation — identifying the prolapsing or flail leaflet segment, the ruptured or elongated chordae, and the degree of annular dilatation; selection of the appropriate repair technique for the identified anatomy — posterior leaflet resection and reconstruction for posterior leaflet prolapse, artificial chordae implantation for anterior leaflet or bileaflet prolapse, chordal transfer for complex prolapse patterns; and annuloplasty ring implantation to restore annular geometry, prevent progressive annular dilatation, and ensure the durability of the repair. The quality of the repair is assessed intraoperatively by transoesophageal echocardiography under physiological loading conditions — confirming the absence of residual regurgitation, the adequacy of the coaptation zone, and the absence of systolic anterior motion of the anterior leaflet. A repair that does not meet these echocardiographic criteria intraoperatively should be revised or converted to replacement rather than accepted — the intraoperative echo is the surgeon's quality control, and the standard it enforces is the standard that determines the patient's long-term outcome.

2. Combined Cardiac Surgery: Rationale, Risk-Benefit Analysis, and Patient Selection for Simultaneous Multi-Lesion Correction

The decision to perform combined cardiac surgery — addressing multiple cardiac pathologies simultaneously in a single operation — requires a careful risk-benefit analysis that weighs the increased immediate operative complexity of the combined procedure against the cumulative risk of staged operations and the haemodynamic burden of leaving uncorrected lesions in place during staged recoveries. The case for combined surgery is strongest when: all lesions are independently symptomatic or haemodynamically significant; each lesion would independently warrant surgical correction; the patient's physiological reserve is sufficient to tolerate the anticipated cardiopulmonary bypass time; and the surgical team has the expertise to perform all components of the combined procedure to a high technical standard. In this case, all four criteria were met: the mitral regurgitation, coronary artery disease, and ASD each independently warranted correction; the patient's cardiac function, while impaired, was sufficient to tolerate a combined procedure; and the Ruijin Hospital cardiac surgery team has extensive experience in combined valve, coronary, and congenital heart surgery. The combined approach delivered a single, comprehensive correction of the patient's complete cardiac anatomy — eliminating the haemodynamic burden of all three lesions simultaneously and allowing a single, unified recovery rather than the cumulative burden of staged procedures.

3. Multidisciplinary Collaboration in Complex Cardiac Surgery: The Organisational Foundation of Safe Outcomes

The successful management of complex combined cardiac surgery requires a level of multidisciplinary integration that encompasses preoperative planning, intraoperative execution, and postoperative management. Cardiology contributes the detailed haemodynamic characterisation of each lesion and the assessment of cardiac function that defines the surgical risk and informs the operative strategy. Anaesthesia manages the haemodynamic consequences of cardiopulmonary bypass, myocardial protection, and the physiological stresses of a 6-hour combined cardiac operation — maintaining perfusion pressure, managing fluid balance, and supporting the cardiovascular system through the transition from bypass to native cardiac function. The perfusion team manages the cardiopulmonary bypass circuit and myocardial protection strategy — optimising the conditions for cardiac surgery and minimising the ischaemic burden on the myocardium during the period of aortic cross-clamping. The ICU provides the postoperative monitoring and support infrastructure that allows the heart to recover its function in the days following major cardiac surgery — managing the haemodynamic consequences of the combined procedure, supporting cardiac output, and detecting and managing early complications. The integration of these disciplines — from the preoperative MDT discussion through the intraoperative team coordination to the postoperative ICU management — is the organisational foundation on which safe outcomes in complex combined cardiac surgery are built.

How CMCS Shanghai Coordinated This Case

CMCS Shanghai supported the patient and family throughout the diagnostic, surgical, and recovery pathway at Ruijin Hospital, Shanghai Jiao Tong University, including: priority consultation coordination with Prof. Mei Ju's cardiac surgery team, with bilingual review of all prior echocardiography, coronary CTA, cardiac MRI, and clinical records; bilingual interpretation throughout the MDT discussion, surgical planning consultation, and all postoperative review appointments; bilingual explanation of the combined surgical strategy — the rationale for simultaneous mitral valve repair, CABG, and ASD closure, the surgical techniques for each component, the expected operative duration, and the postoperative recovery pathway; coordination of preoperative echocardiography, coronary CTA, cardiac MRI, and anaesthetic evaluation with bilingual results communication and clinical summary; bilingual surgical consent process — ensuring the patient and family had a complete understanding of the combined procedure, the repair versus replacement decision for the mitral valve, the bypass grafting strategy, the ASD closure technique, and the postoperative monitoring plan; postoperative ICU and ward coordination including bilingual communication of recovery milestones, cardiac function trends, and discharge planning; and long-term cardiac follow-up coordination including echocardiographic surveillance scheduling and bilingual communication of surveillance results.

For international patients with complex cardiac disease — including those with concurrent valve disease, coronary artery disease, and congenital heart defects requiring combined surgical correction — Prof. Mei Ju's team at Ruijin Hospital, Shanghai Jiao Tong University, offers access to one of China's most advanced cardiac surgery programmes. CMCS ensures that expertise is accessible: in the patient's language, with every step of the diagnostic, surgical, and surveillance pathway coordinated and communicated clearly, from the first specialist consultation through long-term cardiac follow-up.

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.