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Ann Thorac Surg 1995;59:56-59
© 1995 The Society of Thoracic Surgeons

Isolated Cleft Mitral Valve: Valve Reconstruction Techniques

Herz und Gefäss Klinik, Bad Neustadt/Saale, Germany

Accepted for publication June 22, 1994.

	Abstract

Top Footnotes Abstract Introduction Methods and Results Comment References

 
Reports concerning an isolated cleft of the anterior mitral valve are rare. This congenital anomaly of the mitral valve is usually repaired by suturing the edges of the cleft. We report 4 cases of isolated anterior mitral cleft. The patients ranged in age from 13 to 41 years. The clinical symptoms were those typical of mitral insufficiency. In all 4 patients, preoperative echocardiography was able to establish the exact anatomic diagnosis. In 1 patient, the cleft was directly sutured, whereas, in the other 3 patients, a fibrous reaction of the edges of the cleft with a subsequent lack of valvular tissue made direct suture technically impossible. Instead, the fibrous edges of the cleft were resected and the anterior leaflet of the mitral valve was reconstructed using an autologous pericardial patch pretreated with buffered glutaraldehyde. All 4 patients underwent annuloplasty together with placement of a Carpentier mitral ring. Postoperative echocardiograms have confirmed good results of the repair; 1 patient has a trivial insufficiency and 3 have a completely competent mitral valve.

	Introduction

Top Footnotes Abstract Introduction Methods and Results Comment References

 
A cleft of the anterior leaflet of the mitral valve is usually associated with a septal defect of the endocardial cushion type (an atrioventricular septal defect). A cleft of the anterior mitral valve as an isolated anomaly is a rare cause of congenital mitral valve insufficiency [1–7]. Suturing of the cleft has been the only conservative surgical treatment carried out in the cases reported [4–20]. Four patients with an isolated cleft of the anterior leaflet of the mitral valve were operated on at our institution. The anatomic conditions allowed direct suturing of the cleft in 1 patient, but, in the other 3, the anterior mitral valve was partially replaced with an autologous pericardial patch treated with glutaraldehyde. We report our experience in these 4 patients, with a particular emphasis on the surgical techniques used.

	Methods and Results

Top Footnotes Abstract Introduction Methods and Results Comment References

 
Between July 1990 and March 1993, 4 patients underwent mitral valve repair for an isolated cleft of the anterior leaflet of the mitral valve. The patient characteristics are summarized in Table 1. There were 2 male and 2 female patients.

Left ventricular cineangiography revealed the presence of severe mitral regurgitation in all patients. No patient had a gooseneck deformity or a clearly visible cleft of the anterior leaflet of the mitral valve. The atrial and ventricular septa were intact in all 4 patients.

Preoperative Echocardiographic Findings
The 4 patients underwent complete M-mode, two-dimensional and Doppler echocardiographic study using Vingmed CFM-750 ultrasound equipment (Vingmed, Horten, Norway) before and after operation. In each patient, standard parasternal long-axis and short-axis as well as apical views were obtained. The characteristics studied are summarized in Table 1. Left ventricular outflow tract velocity was measured with continuous-wave Doppler ultrasound to look for a subaortic obstruction.

The mitral valve insufficiency was found to be severe in all 4 patients. The parasternal short-axis view clearly demonstrated the cleft anterior mitral valve leaflet in the 4 patients. Huge annulus deformation and dilatation was recognized in the 4 patients as an associated mechanism responsible for the mitral valve insufficiency. No accessory chordae tendineae and no left ventricular outflow tract obstruction were observed, and no atrial or ventricular septal defect could be detected. In patient 2, echocardiography confirmed the presence of a moderate tricuspid insufficiency stemming from dilatation of the annulus.

Operative Findings and Surgical Techniques
The cardiopulmonary bypass and aortic cross-clamping times were 97 ± 7 and 63.2 ± 7.4 minutes, respectively.

In patient 1, the cleft was not at the level of the center of the leaflet, the posterior portion of the anterior leaflet being wider than the anterior portion. The cleft extended for 75% of the distance between the free margin and the base of the anterior mitral leaflet. The cleft was I-shaped. The junction between the edges of the cleft and the free edge of the anterior mitral leaflet was sharp and assumed a 90-degree angle. The edges of the cleft were relatively thin and smooth. The entire length of the cleft was sutured with 5-0 monofilament interrupted sutures (Teflex; Laboratoires Peters, Bobigny, France), imparting a near-normal appearance to the mitral valve with the exception of dilatation of the annulus. A No. 32 Carpentier-Edwards mitral ring (Baxter Healthcare, Santa Ana, CA) was then implanted (Fig 1).

View larger version (16K): [in this window] [in a new window]   Fig 1. . Surgical steps involved in directly suturing an isolated cleft of the mitral valve.

View larger version (16K): [in this window] [in a new window]   Fig 2. . Surgical steps involved in resecting the cleft area of the anterior leaflet and reconstructing this leaflet with an autologous pericardial patch pretreated with glutaraldehyde.

In Patient 2, the right atrium was opened to allow inspection of the tricuspid valve. An unsuspected patent foramen ovale was discovered and closed with a direct suture. The tricuspid annulus was found to be widely dilated and a No. 34 Carpentier-Edwards ring was implanted.

Postoperative Echocardiography
The 4 patients underwent echocardiography before discharge. In 3, the mitral valve was noted to be totally competent, but trivial regurgitation was present in the fourth. The postoperative echocardiographic findings are given in Table 1.

Follow-up
The patients have been followed up for 42, 28, 19, and 16 months after operation. All 4 are in New York Heart Association functional class I in sinus rhythm and none require anticoagulation or any cardiac medication. Follow-up echocardiography has shown very stable results, with a totally competent mitral valve in 3 patients and trivial regurgitation in 1.

	Comment

Top Footnotes Abstract Introduction Methods and Results Comment References

 
Isolated cleft of the mitral valve is a rare congenital malformation that was first described in 1954 [21]. The nosologic relationship between the isolated mitral cleft and the endocardial cushion defect remains controversial.

Anatomic and echocardiographic studies have shown that some anatomic features are specific to the isolated mitral cleft [19, 22]: unlike the endocardial cushion defect, the mitral annulus is in a normal position, the cleft points toward the left ventricular outflow tract, and the mitral and tricuspid valves are attached to the septum at different levels, with the tricuspid valve attached more inferiorly. As pointed out by Anderson and associates [23], approximating the two edges of the breach restores the normal anatomy of the anterior leaflet of the mitral valve in the setting of an isolated cleft mitral valve. However, approximating the two segments of the divided anterior leaflet of the left valve in the setting of an atrioventricular septal defect does not produce a normal anterior mitral valve.

Except in rare cases [24, 25], an isolated cleft mitral valve is usually associated with a mitral valve insufficiency that requires surgical intervention. It is now generally agreed that, when feasible, mitral repair is preferable to mitral valve replacement [26, 27]. As reported here, direct suture of the cleft is not always technically feasible because of the lack of valvular tissue. In these difficult cases, techniques that extend the anterior leaflet make this feasible and the functional outcome of valve repair is probably improved, with a totally competent valve the end result. Glutaraldehyde-treated autologous pericardium has been the preferred patch material in these operations. Results from experimental and clinical studies that have assessed the qualities of the material have proved its stability and reliability [28, 29].

It is of interest that a suture of the cleft was possible only in the youngest patient, aged 13 years. Di Segni and Edwards [22] have already observed that a relationship exists between the age of the patients and the thickness of the cleft edges.

The role of echocardiography in the diagnosis of the defect should be emphasized, as it has the specific capacity to differentiate a cleft mitral valve from other causes of congenital mitral valve insufficiency [19, 24, 30].

In conclusion, an isolated cleft mitral valve is a rare cause of congenital mitral valve insufficiency. Whenever feasible, suturing of the cleft and eventually annuloplasty should be carried out. When there is a lack of substance due to fibrous shrinkage of the valvular tissue, resection of the edges of the cleft together with partial replacement of the anterior leaflet using autologous glutaraldehyde-treated pericardium accomplishes a valve reconstruction associated with a good functional result.

	Footnotes

Top Footnotes Abstract Introduction Methods and Results Comment References

 
Address reprint requests to Dr Perier, Herz und Gefäss Klinik, Salzburger Leite 1, 97616 Bad Neustadt/Saale, Germany.

	References

Top Footnotes Abstract Introduction Methods and Results Comment References

 

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Perier, P. Articles by Clausnizer, B. Search for Related Content PubMed PubMed Citation Articles by Perier, P. Articles by Clausnizer, B.