Totally Endoscopic Mitral Valve Repair for Barlow’s Disease in a Patient With Severe Pulmonary Dysfunction Following COVID-19 Pneumonia: A Case Report

We report a case of totally endoscopic mitral valve repair for severe mitral regurgitation (MR) due to Barlow's disease in a 55-year-old man with severe pulmonary dysfunction following coronavirus disease 2019 (COVID-19) pneumonia. He had developed severe COVID-19 one month earlier, requiring veno-venous extracorporeal membrane oxygenation (V-V ECMO). Although successfully weaned from ECMO, the patient continued to experience persistent fever and was referred to our department for suspected acute MR. Transthoracic echocardiography revealed severe MR with significant bileaflet prolapse. Given the compromised pulmonary status and prior mini-tracheostomy, we opted for totally endoscopic mitral valve repair via a three-port approach using a 3D endoscope. Intraoperative findings confirmed no signs of infection but revealed characteristic thickening and billowing of both mitral leaflets, consistent with Barlow's disease. Annuloplasty was performed using a 34-mm Physio Flex ring (Edwards Lifesciences, Irvine, CA, USA). The patient was extubated six hours after surgery without complications, and postoperative echocardiography confirmed complete resolution of MR. He was transferred back to the referring hospital on postoperative day nine for continued rehabilitation and steroid therapy. This case suggests that totally endoscopic mitral valve repair may be a feasible and safe option even for patients with severe pulmonary dysfunction following COVID-19-related lung injury.