Left Tuberculous Destroyed Lung Complicated with Rheumatic Mitral Valve Disease: A Case Report with Intraoperative Respiratory Maintenance via Visual Laryngeal Mask

Left Tuberculous Destroyed Lung Complicated with Rheumatic Mitral Valve Disease: A Case Report with Intraoperative Respiratory Maintenance via Visual Laryngeal Mask | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Left Tuberculous Destroyed Lung Complicated with Rheumatic Mitral Valve Disease: A Case Report with Intraoperative Respiratory Maintenance via Visual Laryngeal Mask Aiting Lin, Huan Li, Xiaodong Cai, Jingli Lin, Kangcong Zhang, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9228835/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 12 You are reading this latest preprint version Abstract Tuberculous destroyed lung (TDL) is a severe irreversible sequela of chronic pulmonary tuberculosis, characterized by extensive parenchymal destruction, fibrosis and volume loss, which leads to significant ventilatory dysfunction. Combined with rheumatic mitral valve disease (RMVD), such patients face extremely high challenges in intraoperative respiratory management and surgical safety. Herein, we report a case of a 56-year-old female with left TDL complicated with severe mitral regurgitation and moderate mitral stenosis who underwent biological mitral valve replacement, tricuspid annuloplasty, left atrial appendage amputation and pulmonary vein isolation under cardiopulmonary bypass, with the surgical procedure consistent with the medical record. A visual laryngeal mask was innovatively adopted for intraoperative respiratory maintenance instead of traditional endotracheal intubation, and the visual laryngeal mask was extubated immediately after the operation, which effectively ensured stable oxygenation and ventilation throughout the operation despite the patient’s unilateral effective pulmonary ventilation. Postoperatively, the patient developed mild right pleural effusion, which was relieved by thoracentesis, and no severe respiratory complications such as hypoxemia or acute respiratory distress syndrome occurred. The patient was discharged stably after 26 days of hospitalization, and the 3-month follow-up showed good recovery of cardiac and respiratory function. This case highlights the clinical value of visual laryngeal mask in intraoperative respiratory management for patients with TDL complicated with cardiac valve disease, and emphasizes the importance of multidisciplinary team (MDT) collaboration and fast-track anesthesia in preoperative evaluation, surgical planning, intraoperative management and postoperative complication control for such high-risk patients. Tuberculous destroyed lung Rheumatic mitral valve disease Visual laryngeal mask Intraoperative respiratory management Mitral valve replacement Figures Figure 1 Introduction Tuberculous destroyed lung is a chronic and irreversible pulmonary lesion caused by long-term, inadequately treated pulmonary tuberculosis, with an incidence of approximately 5%-10% in patients with chronic pulmonary tuberculosis [ 1 ] . The pathological features include extensive lung tissue necrosis, cavity formation, pulmonary fibrosis and severe volume loss, often resulting in restrictive or mixed ventilatory dysfunction, and even respiratory insufficiency in severe cases [ 2 ] . When combined with rheumatic mitral valve disease, the patient’s cardiac and pulmonary function are both compromised, leading to increased perioperative risks such as hypoxemia, heart failure and infection, and intraoperative respiratory management becomes the core link to ensure surgical success [ 3 ] . Traditional intraoperative respiratory support for cardiac surgery mostly adopts endotracheal intubation, which has the advantages of reliable ventilation, but it is invasive to the airway and may cause complications such as laryngeal edema, hoarseness and airway infection, especially for patients with poor pulmonary function, who have low tolerance to tracheal intubation [ 4 ] . The visual laryngeal mask is a new type of supraglottic airway management device, which integrates the advantages of simple operation, minimal airway trauma and real-time visual positioning, and can effectively establish a patent airway and provide stable ventilatory support [ 5 ] . At present, there are few reports on the application of visual laryngeal mask in intraoperative respiratory maintenance for patients with TDL complicated with cardiac valve disease. This case reports the clinical diagnosis, surgical treatment and perioperative management of such a patient, aiming to provide a reference for the clinical treatment of similar high-risk cases. The study was approved by the Institutional Review Board of Zhongshan Xiaolan People's Hospital & Zhongshan Fifth People's Hospital. Case Presentation A 56-year-old female patient was admitted to our hospital, due to "recurrent chest tightness and shortness of breath for 10 days aggravated by activity". The patient had a history of pulmonary tuberculosis 20 years ago, with anti-tuberculosis drug treatment for 6 months, and no regular follow-up after symptom relief. She had no history of hypertension, diabetes or coronary heart disease, and denied smoking and drinking history. Preoperative examinations : Chest computed tomography (CT) showed extensive destruction of the left lung with multiple cavities, fibrosis and calcification, significant reduction in left lung volume and leftward mediastinal shift; scattered chronic inflammatory foci and old tuberculosis foci were found in the right lung (Fig. 1 A, B). Transthoracic echocardiography revealed rheumatic mitral valve disease, severe mitral regurgitation, moderate mitral stenosis, mild tricuspid regurgitation, atrial fibrillation and severe cardiac enlargement (left atrial diameter 56 mm, left ventricular end-diastolic diameter 52 mm). Pulmonary function test indicated mild to moderate restrictive ventilatory dysfunction, with forced vital capacity (FVC) 1.8 L, forced expiratory volume in 1 second (FEV1) 1.2 L, and FEV1/FVC 66.7%. Laboratory tests showed mild anemia (hemoglobin 98 g/L), hypoalbuminemia (albumin 32 g/L), elevated N-terminal pro-brain natriuretic peptide (NT-proBNP) 1250 pg/mL, and normal white blood cell count and inflammatory indicators (procalcitonin 0.15 ng/mL, C-reactive protein 8 mg/L). Physical examination on admission: body temperature 36.8℃, heart rate 88 beats/min (irregular rhythm), respiratory rate 20 breaths/min, blood pressure 122/58 mmHg; mild cyanosis of the lips, absent breath sounds of the left lung, slightly rough breath sounds of the right lung without rales; grade 3/6 systolic murmur at the mitral valve area, irregular heart rhythm; no lower extremity edema. Preoperative MDT evaluation : A multidisciplinary team consisting of anesthesiologists, thoracic and cardiac surgeons, respiratory physicians, critical care physicians and radiologists conducted a comprehensive evaluation. The diagnosis was confirmed as: 1. Left tuberculous destroyed lung; 2. Rheumatic mitral valve disease (severe regurgitation + moderate stenosis); 3. Atrial fibrillation; 4. Hypoalbuminemia; 5. Mild anemia. The MDT determined that the patient had clear surgical indications for cardiac valve surgery, with no absolute contraindications. Considering the patient’s left lung destruction and unilateral effective ventilation, the anesthesiology team proposed to use a visual laryngeal mask for intraoperative respiratory maintenance to reduce airway trauma and ensure ventilatory safety. Surgical and Postoperative Course The patient underwent surgery, with general anesthesia induced by intravenous midazolam 2 mg, fentanyl 50 µg, propofol 100 mg and rocuronium bromide 50 mg. After induction, a size 4 visual laryngeal mask was inserted under the monitoring of the visual laryngoscope, with no air leakage found after positive pressure ventilation, and the laryngeal mask was fixed with medical tape. Intraoperative ventilatory parameters were set as: tidal volume 6–8 mL/kg, respiratory rate 12–14 times/min, inspiratory-expiratory ratio 1:2, oxygen concentration 80%-100%. During the operation, the patient’s blood oxygen saturation (SpO₂) was maintained at 98%-100%, end-tidal carbon dioxide partial pressure (PetCO₂) at 35–45 mmHg, and respiratory rhythm was stable. Intraoperatively, cardiopulmonary bypass was established, and it was found that the left lung was severely atrophic and adhered to the chest wall, the heart was severely enlarged, and the mitral valve was calcified and contracted with severe valvular regurgitation and stenosis.Biological mitral valve replacement, tricuspid annuloplasty with a prosthetic ring, left atrial appendage amputation and pulmonary vein isolation were successfully performed in accordance with the medical record. The total intraoperative blood loss was about 800 mL, and the patient received transfusion of 4 U of suspended red blood cells, 400 mL of fresh frozen plasma and 1 U of platelets to correct anemia and coagulation dysfunction. The operation lasted 4.5 hours, and the visual laryngeal mask remained well fixed without displacement or air leakage throughout the operation. Immediately after the end of the operation, the visual laryngeal mask was extubated when the patient recovered spontaneous breathing, had stable hemodynamics and clear consciousness.Postoperatively, the patient was transferred to the intensive care unit (ICU) for close monitoring, and the visual laryngeal mask was retained for 6 hours with continued ventilator-assisted ventilation. The patient regained consciousness 4 hours after surgery with stable spontaneous breathing, and the visual laryngeal mask was removed and replaced with high-flow nasal oxygen therapy (SpO₂ 97%-99%). On the first postoperative day, the patient developed mild right pleural effusion, which was treated with ultrasound-guided thoracentesis and fluid aspiration (total aspirated fluid 300 mL of light yellow exudate). No severe complications such as low cardiac output syndrome, acute respiratory distress syndrome (ARDS) or infection occurred during the ICU stay. The patient was transferred back to the thoracic and cardiac surgery ward, with continued anticoagulation, anti-infection, nutritional support and atomization inhalation treatment. The patient’s surgical incision healed well without redness, swelling or exudation. Reexaminations on the preoperative discharge showed normal cardiac color Doppler ultrasound (good function of the artificial biological valve, no obvious valvular regurgitation), stable chest CT (no progression of right lung lesions, no new pleural effusion), and normalized blood routine and liver and kidney function. The patient was discharged, with a total hospitalization of 26 days. Discharge recommendations included oral anticoagulant drugs for 6 months, regular monitoring of coagulation function, avoidance of fatigue and cold, and regular follow-up of cardiac color Doppler ultrasound and chest CT at 1, 3 and 6 months after discharge. The 3-month postoperative follow-up showed that the patient had no chest tightness, shortness of breath or cough, and normal daily activities; physical examination showed clear breath sounds of the right lung, regular heart rhythm and no murmur at the mitral valve area; reexamination of cardiac color Doppler ultrasound indicated normal function of the artificial valve and no cardiac enlargement; chest CT showed stable left TDL lesions and no abnormal changes in the right lung. Discussion This case is a typical case of left TDL complicated with severe RMVD, with the core clinical challenge being the safe implementation of cardiac valve surgery under the condition of unilateral pulmonary ventilation and poor pulmonary function. The key to the success of this case lies in the innovative application of visual laryngeal mask for intraoperative respiratory maintenance combined with fast-track anesthesia and immediate postoperative extubation, as well as the comprehensive perioperative management under MDT collaboration, which provides four key clinical insights for the treatment of similar patients. First, the visual laryngeal mask has unique advantages in intraoperative respiratory management for patients with TDL. [ 4 , 5 ] Traditional endotracheal intubation is the gold standard for respiratory support in cardiac surgery, but for patients with TDL with unilateral effective ventilation, the invasive damage of tracheal intubation may lead to airway edema and further reduce respiratory function, and the risk of postoperative respiratory complications is significantly increased. [ 5 ] The visual laryngeal mask used in this case realizes real-time positioning during insertion through the visual laryngoscope, which ensures the tight fit of the mask and the laryngeal orifice and avoids air leakage; at the same time, it is a supraglottic airway device with minimal trauma, which reduces the stimulation to the larynx and trachea, and the patient has good tolerance. During the whole operation, the patient’s SpO₂ and PetCO₂ were maintained in the normal range, and no respiratory-related complications occurred after surgery, which confirmed the safety and effectiveness of the visual laryngeal mask in such patients. When applying the visual laryngeal mask, it is necessary to select the appropriate size according to the patient’s body shape, ensure gentle operation during insertion to avoid pharyngeal mucosa damage, and closely monitor the mask position and ventilatory parameters during the operation. Second, the implementation of fast-track anesthesia is a crucial measure to improve the perioperative prognosis of high-risk cardiac surgery patients with TDL. Fast-track anesthesia aims to minimize the invasive damage of anesthesia and surgery, accelerate the recovery of patients’ spontaneous breathing and hemodynamic stability, and realize early extubation, which is particularly suitable for TDL patients with poor pulmonary reserve function. In this case, the anesthesiology team adopted a low-dose anesthetic induction and maintenance protocol, combined with the minimally invasive visual laryngeal mask for airway management, which reduced the inhibitory effect of anesthetics on the respiratory and circulatory system, enabled the patient to recover spontaneous breathing and clear consciousness immediately after the operation, and successfully completed immediate extubation. Fast-track anesthesia not only reduced the risk of ventilator-associated pneumonia and airway injury in the patient, but also shortened the ICU monitoring time and accelerated the postoperative recovery, which is an important innovation in the anesthesia management of such high-risk patients. Third, comprehensive preoperative MDT evaluation is the premise to ensure the safety of high-risk surgery and the smooth implementation of fast-track anesthesia. For patients with TDL complicated with cardiac valve disease, the cardiac and pulmonary function are both compromised, and the preoperative evaluation needs to involve multiple disciplines such as anesthesiology, cardiac surgery, respiratory medicine and critical care medicine. The MDT team of this case comprehensively evaluated the patient’s lung destruction range, cardiac valve lesion degree, ventilatory function and coagulation status, accurately assessed the surgical and anesthesia risks, and formulated an individualized plan of "visual laryngeal mask respiratory support + fast-track anesthesia + standardized cardiac valve surgery consistent with medical records", which avoided the risks of tracheal intubation and the long-term anticoagulation complications of mechanical valves, and laid a solid foundation for the success of the operation and immediate postoperative extubation. Fourth, targeted postoperative management is crucial to prevent complications in patients with TDL after fast-track anesthesia and immediate extubation. Patients with TDL have poor pulmonary reserve function, and postoperative pleural effusion, infection and respiratory insufficiency are common complications [ 6 ] . In this case, the medical team closely monitored the patient’s respiratory status, hemodynamics and chest imaging changes after immediate extubation, and timely performed thoracentesis for the mild right pleural effusion, which effectively prevented the progression of effusion to respiratory failure. In addition, the combination of anticoagulation, nutritional support and atomization inhalation treatment effectively promoted the recovery of cardiac and respiratory function, and ensured the stable discharge of the patient. At the same time, this case also has certain limitations: it is a single case report, and the clinical evidence is limited; the long-term prognosis of the patient needs further follow-up, especially the long-term function of the artificial biological valve and the stability of TDL lesions. In the future, multi-center, large-sample clinical studies are needed to further verify the application value of visual laryngeal mask in intraoperative respiratory management for patients with TDL complicated with cardiac valve disease, and to explore more optimized perioperative management strategies. In conclusion , left tuberculous destroyed lung complicated with rheumatic mitral valve disease is a high-risk clinical condition with great challenges in perioperative management. The standardized surgical procedure consistent with medical records is the basis for the treatment of such patients, and the application of visual laryngeal mask for intraoperative respiratory maintenance combined with fast-track anesthesia and immediate postoperative extubation can effectively ensure the stability of intraoperative oxygenation and ventilation, reduce airway trauma, accelerate postoperative recovery and improve the surgical safety of such patients. Comprehensive preoperative MDT evaluation, individualized surgical and anesthesia plans based on fast-track concept, and targeted postoperative complication management are the core measures to improve the clinical outcomes of such patients, which are worthy of clinical promotion and application. Declarations Patient consent Written informed consent for the publication of this case report was obtained from the patient. A n ethics statement The study was approved by the Institutional Review Board of Zhongshan Xiaolan People's Hospital & Zhongshan Fifth People's Hospital. Funding section None of funding. Competing Interest declaration None of competing Interest. References Park DW, Kim BG, Jeong YH, et al. Risk of short- and long-term pulmonary complications should be determined before surgery for tuberculosis-destroyed lung. J Thorac Dis. 2023;15:950-952. Liu W, Xu Y, Yang L, et al. Risk factors associated with pulmonary hypertension in patients with active tuberculosis and tuberculous destroyed lung: a retrospective study. Sci Rep. 2024;14:10108. Knox A, Bennetts JS, Gimpel D, et al. Transcatheter mitral valve-in-valve: treatment of rheumatic heart disease in young patients. ANZ J Surg. 2022;92:3298-3303. Menna C, Fiorelli S, Massullo D, Ibrahim M, Rocco M, Rendina EA. Laryngeal mask versus endotracheal tube for airway management in tracheal surgery: a case-control matching analysis and review of the current literature. Interact Cardiovasc Thorac Surg. 2021;33:426-433. Zhao L, Zhang J, Zhou Q, Jiang W. Comparison of a new visual stylet (Discopo)-guided laryngeal mask airway placement vs conventional blind technique: a prospective randomized study. J Clin Anesth. 2016;35:85-89. Jankovic RJ, Dinic V, Markovic D. Pre and postoperative risk management: the role of scores and biomarkers. Curr Opin Anaesthesiol. 2020;33:475-480. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 30 Apr, 2026 Reviews received at journal 25 Apr, 2026 Reviewers agreed at journal 24 Apr, 2026 Reviews received at journal 24 Apr, 2026 Reviewers agreed at journal 24 Apr, 2026 Reviews received at journal 23 Apr, 2026 Reviewers agreed at journal 23 Apr, 2026 Reviewers invited by journal 21 Apr, 2026 Editor invited by journal 27 Mar, 2026 Editor assigned by journal 27 Mar, 2026 Submission checks completed at journal 27 Mar, 2026 First submitted to journal 25 Mar, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9228835","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":630398035,"identity":"074dc1a1-a646-4fe5-a49d-29ad9a5677c2","order_by":0,"name":"Aiting Lin","email":"","orcid":"","institution":"University of Electronic Science and Technology of China","correspondingAuthor":false,"prefix":"","firstName":"Aiting","middleName":"","lastName":"Lin","suffix":""},{"id":630398038,"identity":"fa15e0f3-3740-413c-b9a8-a0e1536d67b2","order_by":1,"name":"Huan Li","email":"","orcid":"","institution":"University of Electronic Science and Technology of 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Yang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA/0lEQVRIiWNgGAWjYDADAwYG9h+Sf2wYGCRI0MIgYdmQRqqWyobDhLUYHD97+OWXmjt22yWSHxjc3HHenl+6x4DhR8U23FrO5KVZyxx7lrxzRppB4swztxNnzjljwNhz5jZuLQdyzIwl2A4nG9xIMDgswXY7weBGjgEzYxseLeffALX8A2lJ/9j8h+2cPWEtN3KMH35sO2wHYjBIth1g3EBIi+SNN2bMjH2HEwzOvCljkDiTnDhzRlrBQXx+4TufY/zxx7fD9gbH07cxSFTY2fNLJG988KMCtxaFAwxs0jwMDIkNyKIHcKoHAvkGBuaPPxgY7PEpGgWjYBSMghEOAMTcYqWnehMcAAAAAElFTkSuQmCC","orcid":"","institution":"University of Electronic Science and Technology of China","correspondingAuthor":true,"prefix":"","firstName":"Ganghua","middleName":"","lastName":"Yang","suffix":""}],"badges":[],"createdAt":"2026-03-26 03:53:03","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9228835/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9228835/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":108391147,"identity":"67d222ba-08ce-4269-8283-795be2e2fde8","added_by":"auto","created_at":"2026-05-04 07:04:29","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":359397,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFigure 1A.\u003c/strong\u003e Preoperative chest computed tomography (CT) coronal reconstruction\u003c/p\u003e\n\u003cp\u003eCoronal CT reconstruction of the chest demonstrates extensive destruction of the left lung with near-complete parenchymal loss, cavitation, fibrosis, and calcification, consistent with tuberculous destroyed lung. The right lung shows scattered chronic tuberculous foci and emphysematous changes, with preserved but compromised pulmonary function (white arrows).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFigure 1B.\u003c/strong\u003e Preoperative chest radiograph (posteroanterior view)\u003c/p\u003e\n\u003cp\u003ePreoperative chest radiograph reveals severe volume loss of the left hemithorax with mediastinal shift to the left, indicative of left tuberculous destroyed lung. The right lung exhibits scattered calcified tuberculous lesions and emphysematous bullae, confirming the preoperative pulmonary functional impairment (white arrows).\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-9228835/v1/e5fb6243e4d02c9ccb5ad21a.png"},{"id":108804070,"identity":"c670f8c2-8420-41b1-bbd4-df8c3d1067d0","added_by":"auto","created_at":"2026-05-08 15:15:18","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":614786,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9228835/v1/3730336f-dc0a-4f42-8adc-ed8b98347b21.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Left Tuberculous Destroyed Lung Complicated with Rheumatic Mitral Valve Disease: A Case Report with Intraoperative Respiratory Maintenance via Visual Laryngeal Mask","fulltext":[{"header":"Introduction","content":"\u003cp\u003eTuberculous destroyed lung is a chronic and irreversible pulmonary lesion caused by long-term, inadequately treated pulmonary tuberculosis, with an incidence of approximately 5%-10% in patients with chronic pulmonary tuberculosis \u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003e. The pathological features include extensive lung tissue necrosis, cavity formation, pulmonary fibrosis and severe volume loss, often resulting in restrictive or mixed ventilatory dysfunction, and even respiratory insufficiency in severe cases \u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e. When combined with rheumatic mitral valve disease, the patient\u0026rsquo;s cardiac and pulmonary function are both compromised, leading to increased perioperative risks such as hypoxemia, heart failure and infection, and intraoperative respiratory management becomes the core link to ensure surgical success \u003csup\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eTraditional intraoperative respiratory support for cardiac surgery mostly adopts endotracheal intubation, which has the advantages of reliable ventilation, but it is invasive to the airway and may cause complications such as laryngeal edema, hoarseness and airway infection, especially for patients with poor pulmonary function, who have low tolerance to tracheal intubation \u003csup\u003e[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e. The visual laryngeal mask is a new type of supraglottic airway management device, which integrates the advantages of simple operation, minimal airway trauma and real-time visual positioning, and can effectively establish a patent airway and provide stable ventilatory support \u003csup\u003e[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e. At present, there are few reports on the application of visual laryngeal mask in intraoperative respiratory maintenance for patients with TDL complicated with cardiac valve disease. This case reports the clinical diagnosis, surgical treatment and perioperative management of such a patient, aiming to provide a reference for the clinical treatment of similar high-risk cases.\u003c/p\u003e \u003cp\u003eThe study was approved by the Institutional Review Board of Zhongshan Xiaolan People's Hospital \u0026amp; Zhongshan Fifth People's Hospital.\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cp\u003eA 56-year-old female patient was admitted to our hospital, due to \"recurrent chest tightness and shortness of breath for 10 days aggravated by activity\". The patient had a history of pulmonary tuberculosis 20 years ago, with anti-tuberculosis drug treatment for 6 months, and no regular follow-up after symptom relief. She had no history of hypertension, diabetes or coronary heart disease, and denied smoking and drinking history.\u003c/p\u003e \u003cp\u003e \u003cb\u003ePreoperative examinations\u003c/b\u003e: Chest computed tomography (CT) showed extensive destruction of the left lung with multiple cavities, fibrosis and calcification, significant reduction in left lung volume and leftward mediastinal shift; scattered chronic inflammatory foci and old tuberculosis foci were found in the right lung (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e1\u003c/span\u003eA, B). Transthoracic echocardiography revealed rheumatic mitral valve disease, severe mitral regurgitation, moderate mitral stenosis, mild tricuspid regurgitation, atrial fibrillation and severe cardiac enlargement (left atrial diameter 56 mm, left ventricular end-diastolic diameter 52 mm). Pulmonary function test indicated mild to moderate restrictive ventilatory dysfunction, with forced vital capacity (FVC) 1.8 L, forced expiratory volume in 1 second (FEV1) 1.2 L, and FEV1/FVC 66.7%. Laboratory tests showed mild anemia (hemoglobin 98 g/L), hypoalbuminemia (albumin 32 g/L), elevated N-terminal pro-brain natriuretic peptide (NT-proBNP) 1250 pg/mL, and normal white blood cell count and inflammatory indicators (procalcitonin 0.15 ng/mL, C-reactive protein 8 mg/L). Physical examination on admission: body temperature 36.8℃, heart rate 88 beats/min (irregular rhythm), respiratory rate 20 breaths/min, blood pressure 122/58 mmHg; mild cyanosis of the lips, absent breath sounds of the left lung, slightly rough breath sounds of the right lung without rales; grade 3/6 systolic murmur at the mitral valve area, irregular heart rhythm; no lower extremity edema.\u003c/p\u003e \u003cp\u003e \u003cb\u003ePreoperative MDT evaluation\u003c/b\u003e: A multidisciplinary team consisting of anesthesiologists, thoracic and cardiac surgeons, respiratory physicians, critical care physicians and radiologists conducted a comprehensive evaluation. The diagnosis was confirmed as: 1. Left tuberculous destroyed lung; 2. Rheumatic mitral valve disease (severe regurgitation\u0026thinsp;+\u0026thinsp;moderate stenosis); 3. Atrial fibrillation; 4. Hypoalbuminemia; 5. Mild anemia. The MDT determined that the patient had clear surgical indications for cardiac valve surgery, with no absolute contraindications. Considering the patient\u0026rsquo;s left lung destruction and unilateral effective ventilation, the anesthesiology team proposed to use a visual laryngeal mask for intraoperative respiratory maintenance to reduce airway trauma and ensure ventilatory safety.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eSurgical and Postoperative Course\u003c/h2\u003e \u003cp\u003eThe patient underwent surgery, with general anesthesia induced by intravenous midazolam 2 mg, fentanyl 50 \u0026micro;g, propofol 100 mg and rocuronium bromide 50 mg. After induction, a size 4 visual laryngeal mask was inserted under the monitoring of the visual laryngoscope, with no air leakage found after positive pressure ventilation, and the laryngeal mask was fixed with medical tape. Intraoperative ventilatory parameters were set as: tidal volume 6\u0026ndash;8 mL/kg, respiratory rate 12\u0026ndash;14 times/min, inspiratory-expiratory ratio 1:2, oxygen concentration 80%-100%. During the operation, the patient\u0026rsquo;s blood oxygen saturation (SpO₂) was maintained at 98%-100%, end-tidal carbon dioxide partial pressure (PetCO₂) at 35\u0026ndash;45 mmHg, and respiratory rhythm was stable.\u003c/p\u003e \u003cp\u003eIntraoperatively, cardiopulmonary bypass was established, and it was found that the left lung was severely atrophic and adhered to the chest wall, the heart was severely enlarged, and the mitral valve was calcified and contracted with severe valvular regurgitation and stenosis.Biological mitral valve replacement, tricuspid annuloplasty with a prosthetic ring, left atrial appendage amputation and pulmonary vein isolation were successfully performed in accordance with the medical record. The total intraoperative blood loss was about 800 mL, and the patient received transfusion of 4 U of suspended red blood cells, 400 mL of fresh frozen plasma and 1 U of platelets to correct anemia and coagulation dysfunction. The operation lasted 4.5 hours, and the visual laryngeal mask remained well fixed without displacement or air leakage throughout the operation.\u003c/p\u003e \u003cp\u003eImmediately after the end of the operation, the visual laryngeal mask was extubated when the patient recovered spontaneous breathing, had stable hemodynamics and clear consciousness.Postoperatively, the patient was transferred to the intensive care unit (ICU) for close monitoring, and the visual laryngeal mask was retained for 6 hours with continued ventilator-assisted ventilation. The patient regained consciousness 4 hours after surgery with stable spontaneous breathing, and the visual laryngeal mask was removed and replaced with high-flow nasal oxygen therapy (SpO₂ 97%-99%). On the first postoperative day, the patient developed mild right pleural effusion, which was treated with ultrasound-guided thoracentesis and fluid aspiration (total aspirated fluid 300 mL of light yellow exudate). No severe complications such as low cardiac output syndrome, acute respiratory distress syndrome (ARDS) or infection occurred during the ICU stay. The patient was transferred back to the thoracic and cardiac surgery ward, with continued anticoagulation, anti-infection, nutritional support and atomization inhalation treatment.\u003c/p\u003e \u003cp\u003eThe patient\u0026rsquo;s surgical incision healed well without redness, swelling or exudation. Reexaminations on the preoperative discharge showed normal cardiac color Doppler ultrasound (good function of the artificial biological valve, no obvious valvular regurgitation), stable chest CT (no progression of right lung lesions, no new pleural effusion), and normalized blood routine and liver and kidney function. The patient was discharged, with a total hospitalization of 26 days. Discharge recommendations included oral anticoagulant drugs for 6 months, regular monitoring of coagulation function, avoidance of fatigue and cold, and regular follow-up of cardiac color Doppler ultrasound and chest CT at 1, 3 and 6 months after discharge.\u003c/p\u003e \u003cp\u003eThe 3-month postoperative follow-up showed that the patient had no chest tightness, shortness of breath or cough, and normal daily activities; physical examination showed clear breath sounds of the right lung, regular heart rhythm and no murmur at the mitral valve area; reexamination of cardiac color Doppler ultrasound indicated normal function of the artificial valve and no cardiac enlargement; chest CT showed stable left TDL lesions and no abnormal changes in the right lung.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis case is a typical case of left TDL complicated with severe RMVD, with the core clinical challenge being the safe implementation of cardiac valve surgery under the condition of unilateral pulmonary ventilation and poor pulmonary function. The key to the success of this case lies in the innovative application of visual laryngeal mask for intraoperative respiratory maintenance combined with fast-track anesthesia and immediate postoperative extubation, as well as the comprehensive perioperative management under MDT collaboration, which provides four key clinical insights for the treatment of similar patients.\u003c/p\u003e \u003cp\u003eFirst, the visual laryngeal mask has unique advantages in intraoperative respiratory management for patients with TDL.\u003csup\u003e[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e Traditional endotracheal intubation is the gold standard for respiratory support in cardiac surgery, but for patients with TDL with unilateral effective ventilation, the invasive damage of tracheal intubation may lead to airway edema and further reduce respiratory function, and the risk of postoperative respiratory complications is significantly increased.\u003csup\u003e[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e The visual laryngeal mask used in this case realizes real-time positioning during insertion through the visual laryngoscope, which ensures the tight fit of the mask and the laryngeal orifice and avoids air leakage; at the same time, it is a supraglottic airway device with minimal trauma, which reduces the stimulation to the larynx and trachea, and the patient has good tolerance. During the whole operation, the patient\u0026rsquo;s SpO₂ and PetCO₂ were maintained in the normal range, and no respiratory-related complications occurred after surgery, which confirmed the safety and effectiveness of the visual laryngeal mask in such patients. When applying the visual laryngeal mask, it is necessary to select the appropriate size according to the patient\u0026rsquo;s body shape, ensure gentle operation during insertion to avoid pharyngeal mucosa damage, and closely monitor the mask position and ventilatory parameters during the operation.\u003c/p\u003e \u003cp\u003eSecond, the implementation of fast-track anesthesia is a crucial measure to improve the perioperative prognosis of high-risk cardiac surgery patients with TDL. Fast-track anesthesia aims to minimize the invasive damage of anesthesia and surgery, accelerate the recovery of patients\u0026rsquo; spontaneous breathing and hemodynamic stability, and realize early extubation, which is particularly suitable for TDL patients with poor pulmonary reserve function. In this case, the anesthesiology team adopted a low-dose anesthetic induction and maintenance protocol, combined with the minimally invasive visual laryngeal mask for airway management, which reduced the inhibitory effect of anesthetics on the respiratory and circulatory system, enabled the patient to recover spontaneous breathing and clear consciousness immediately after the operation, and successfully completed immediate extubation. Fast-track anesthesia not only reduced the risk of ventilator-associated pneumonia and airway injury in the patient, but also shortened the ICU monitoring time and accelerated the postoperative recovery, which is an important innovation in the anesthesia management of such high-risk patients.\u003c/p\u003e \u003cp\u003eThird, comprehensive preoperative MDT evaluation is the premise to ensure the safety of high-risk surgery and the smooth implementation of fast-track anesthesia. For patients with TDL complicated with cardiac valve disease, the cardiac and pulmonary function are both compromised, and the preoperative evaluation needs to involve multiple disciplines such as anesthesiology, cardiac surgery, respiratory medicine and critical care medicine. The MDT team of this case comprehensively evaluated the patient\u0026rsquo;s lung destruction range, cardiac valve lesion degree, ventilatory function and coagulation status, accurately assessed the surgical and anesthesia risks, and formulated an individualized plan of \"visual laryngeal mask respiratory support\u0026thinsp;+\u0026thinsp;fast-track anesthesia\u0026thinsp;+\u0026thinsp;standardized cardiac valve surgery consistent with medical records\", which avoided the risks of tracheal intubation and the long-term anticoagulation complications of mechanical valves, and laid a solid foundation for the success of the operation and immediate postoperative extubation.\u003c/p\u003e \u003cp\u003eFourth, targeted postoperative management is crucial to prevent complications in patients with TDL after fast-track anesthesia and immediate extubation. Patients with TDL have poor pulmonary reserve function, and postoperative pleural effusion, infection and respiratory insufficiency are common complications \u003csup\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e. In this case, the medical team closely monitored the patient\u0026rsquo;s respiratory status, hemodynamics and chest imaging changes after immediate extubation, and timely performed thoracentesis for the mild right pleural effusion, which effectively prevented the progression of effusion to respiratory failure. In addition, the combination of anticoagulation, nutritional support and atomization inhalation treatment effectively promoted the recovery of cardiac and respiratory function, and ensured the stable discharge of the patient.\u003c/p\u003e \u003cp\u003eAt the same time, this case also has certain limitations: it is a single case report, and the clinical evidence is limited; the long-term prognosis of the patient needs further follow-up, especially the long-term function of the artificial biological valve and the stability of TDL lesions. In the future, multi-center, large-sample clinical studies are needed to further verify the application value of visual laryngeal mask in intraoperative respiratory management for patients with TDL complicated with cardiac valve disease, and to explore more optimized perioperative management strategies.\u003c/p\u003e \u003cp\u003e \u003cb\u003eIn conclusion\u003c/b\u003e, left tuberculous destroyed lung complicated with rheumatic mitral valve disease is a high-risk clinical condition with great challenges in perioperative management. The standardized surgical procedure consistent with medical records is the basis for the treatment of such patients, and the application of visual laryngeal mask for intraoperative respiratory maintenance combined with fast-track anesthesia and immediate postoperative extubation can effectively ensure the stability of intraoperative oxygenation and ventilation, reduce airway trauma, accelerate postoperative recovery and improve the surgical safety of such patients. Comprehensive preoperative MDT evaluation, individualized surgical and anesthesia plans based on fast-track concept, and targeted postoperative complication management are the core measures to improve the clinical outcomes of such patients, which are worthy of clinical promotion and application.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003ePatient consent\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent for the publication of this case report was obtained from the patient.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eA\u003c/strong\u003e\u003cstrong\u003en ethics statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by the Institutional Review Board of Zhongshan Xiaolan People\u0026apos;s Hospital \u0026amp; Zhongshan Fifth People\u0026apos;s Hospital.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding section\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone of funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interest declaration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone of competing Interest.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003ePark DW, Kim BG, Jeong YH, et al. Risk of short- and long-term pulmonary complications should be determined before surgery for tuberculosis-destroyed lung. J Thorac Dis. 2023;15:950-952.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eLiu W, Xu Y, Yang L, et al. Risk factors associated with pulmonary hypertension in patients with active tuberculosis and tuberculous destroyed lung: a retrospective study. Sci Rep. 2024;14:10108.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eKnox A, Bennetts JS, Gimpel D, et al. Transcatheter mitral valve-in-valve: treatment of rheumatic heart disease in young patients. ANZ J Surg. 2022;92:3298-3303.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eMenna C, Fiorelli S, Massullo D, Ibrahim M, Rocco M, Rendina EA. Laryngeal mask versus endotracheal tube for airway management in tracheal surgery: a case-control matching analysis and review of the current literature. Interact Cardiovasc Thorac Surg. 2021;33:426-433.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eZhao L, Zhang J, Zhou Q, Jiang W. Comparison of a new visual stylet (Discopo)-guided laryngeal mask airway placement vs conventional blind technique: a prospective randomized study. J Clin Anesth. 2016;35:85-89.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eJankovic RJ, Dinic V, Markovic D. Pre and postoperative risk management: the role of scores and biomarkers. Curr Opin Anaesthesiol. 2020;33:475-480.\u0026nbsp;\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-anesthesiology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bane","sideBox":"Learn more about [BMC Anesthesiology](http://bmcanesthesiol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bane","title":"BMC Anesthesiology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Tuberculous destroyed lung, Rheumatic mitral valve disease, Visual laryngeal mask, Intraoperative respiratory management, Mitral valve replacement","lastPublishedDoi":"10.21203/rs.3.rs-9228835/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9228835/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eTuberculous destroyed lung (TDL) is a severe irreversible sequela of chronic pulmonary tuberculosis, characterized by extensive parenchymal destruction, fibrosis and volume loss, which leads to significant ventilatory dysfunction. Combined with rheumatic mitral valve disease (RMVD), such patients face extremely high challenges in intraoperative respiratory management and surgical safety. Herein, we report a case of a 56-year-old female with left TDL complicated with severe mitral regurgitation and moderate mitral stenosis who underwent biological mitral valve replacement, tricuspid annuloplasty, left atrial appendage amputation and pulmonary vein isolation under cardiopulmonary bypass, with the surgical procedure consistent with the medical record. A visual laryngeal mask was innovatively adopted for intraoperative respiratory maintenance instead of traditional endotracheal intubation, and the visual laryngeal mask was extubated immediately after the operation, which effectively ensured stable oxygenation and ventilation throughout the operation despite the patient\u0026rsquo;s unilateral effective pulmonary ventilation. Postoperatively, the patient developed mild right pleural effusion, which was relieved by thoracentesis, and no severe respiratory complications such as hypoxemia or acute respiratory distress syndrome occurred. The patient was discharged stably after 26 days of hospitalization, and the 3-month follow-up showed good recovery of cardiac and respiratory function. This case highlights the clinical value of visual laryngeal mask in intraoperative respiratory management for patients with TDL complicated with cardiac valve disease, and emphasizes the importance of multidisciplinary team (MDT) collaboration and fast-track anesthesia in preoperative evaluation, surgical planning, intraoperative management and postoperative complication control for such high-risk patients.\u003c/p\u003e","manuscriptTitle":"Left Tuberculous Destroyed Lung Complicated with Rheumatic Mitral Valve Disease: A Case Report with Intraoperative Respiratory Maintenance via Visual Laryngeal Mask","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-05-04 07:04:18","doi":"10.21203/rs.3.rs-9228835/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"339736215339391812419444073732914258009","date":"2026-04-30T10:58:50+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-25T09:31:05+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"239103838197075125276496318503371749962","date":"2026-04-24T19:23:10+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-24T04:19:08+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"273269546893981027292754971548392487628","date":"2026-04-24T04:17:22+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-23T20:23:05+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"271873829991372524796893224764605685649","date":"2026-04-23T19:45:18+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-21T16:07:30+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-03-27T17:18:47+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-27T06:34:45+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-27T06:33:57+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Anesthesiology","date":"2026-03-26T03:36:04+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-anesthesiology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bane","sideBox":"Learn more about [BMC Anesthesiology](http://bmcanesthesiol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bane","title":"BMC Anesthesiology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"96a05a16-0ab0-48ab-b23c-263410928058","owner":[],"postedDate":"May 4th, 2026","published":true,"recentEditorialEvents":[{"type":"reviewerAgreed","content":"339736215339391812419444073732914258009","date":"2026-04-30T10:58:50+00:00","index":48,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-04T07:04:18+00:00","versionOfRecord":[],"versionCreatedAt":"2026-05-04 07:04:18","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9228835","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9228835","identity":"rs-9228835","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}