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Ann Thorac Surg 1995;59:1027-1029
© 1995 The Society of Thoracic Surgeons

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How to Do It

Mitral Valve Replacement: Technique to Preserve the Subvalvular Apparatus

Regional Department of Cardiac Surgery, Kaiser Permanente Medical Center, Los Angeles, California

Accepted for publication December 16, 1994.

	Abstract

Top Footnotes Abstract Introduction Technique Results Comment References

 
A technique is described for retaining the entire subvalvular apparatus in an anatomic fashion during mitral valve replacement that has resulted in no ventricular outflow tract obstruction or interference by retained chordal structures with prosthetic valve function in 128 patients.

	Introduction

Top Footnotes Abstract Introduction Technique Results Comment References

 
Experimental and clinical studies have established the importance of retaining the subvalvular apparatus during mitral valve replacement [1–4]. This has been accomplished by either preserving the native subvalvular apparatus or replacing the native chordal structures with Gore-Tex (W. L. Gore, Flagstaff, AZ) sutures to maintain the mitral annular-papillary muscle continuity [5–8].

This report describes the method we have developed to retain the subvalvular apparatus in an anatomic fashion. Our technique is based on three principles. These include (1) resection of sufficient tissue to allow implantation of an adequate sized valve, (2) absence of interference with prosthetic valve function by the preserved structures, and (3) avoidance of left ventricular outflow tract obstruction.

	Technique

Top Footnotes Abstract Introduction Technique Results Comment References

 
Standard bicaval cannulation is used, with exposure of the valve through either a classic left atriotomy or a transatrial incision described by us previously [9] as shown in Figure 1. The anterior leaflet is detached from the annulus between the two commissures if the valve is considered nonrepairable. If the anterior leaflet is not extensively diseased, an ellipse of tissue is excised (Fig 2) and the rim of leaflet tissue containing primary chordae is reattached to the anterior annulus using pledgeted mattress sutures to be used subsequently for valve implantation. If the leaflet is thickened or calcified, it is divided into two to five chordal segments depending on the size of the valvular leaflet. Each segment then is trimmed into chordal buttons and reattached to the annulus in an anatomic fashion (Figs 3, 4). The normal geometry probably is maintained better if the anterior leaflet is not subdivided. If leaflet tissue on the chordal button appears to be excessive and cannot be excised, a tonsil clamp is used to hold it on the atrial side of the annulus when the valve sutures are tied; this will prevent it from protruding into the left ventricular outflow tract or interfering with prosthetic valve function. A 4-0 Prolene (Ethicon, Somerville, NJ) suture is used to attach markedly redundant leaflet tissue to the left atrial endocardium to prevent its extension over the sewing ring. Experience with double-valve (aortic and mitral) procedures has provided the opportunity to visualize the left ventricular cavity through the open aorta and observe the relationship of retained anterior leaflet structures to the left ventricular outflow tract. Obstruction becomes problematic only when excessive anterior leaflet tissue is retained on the left ventricular aspect of the mitral annulus.

View larger version (50K): [in this window] [in a new window]   Fig 1. . Transatrial incision beginning on right superior pulmonary vein extending to fossa ovalis.

View larger version (50K): [in this window] [in a new window]   Fig 2. . Detaching anterior leaflet from annulus and trimming to create strip of leaflet with attached chordae tendinae and reattaching this strip to anterior annulus with valve sutures.

View larger version (55K): [in this window] [in a new window]   Fig 3. . Detachment of anterior leaflet from annulus and division into two to five chordal buttons.

View larger version (65K): [in this window] [in a new window]   Fig 4. . Reattaching chordal buttons to anterior annulus and rolling posterior leaflet up into annulus with horizontal mattress pledgeted valve sutures.

All of the native chordal structures are resected if the subvalvular apparatus is markedly diseased, as in patients with rheumatic disease where there is fusion of the chordae tendinae, foreshortening of the chordal apparatus, and papillary muscle thickening. Continuity between the mitral annulus and the papillary muscle then is recreated with 4-0 Gore-Tex sutures to produce artificial chordae tendinae that extend from the heads of the papillary muscle to the annulus (Fig 5).

View larger version (46K): [in this window] [in a new window]   Fig 5. . Replacing native subvalvular apparatus with 4-0 Gore-Tex sutures to create artificial chordae. These sutures must be locked at annular level after confirming appropriate length.

	Results

Top Footnotes Abstract Introduction Technique Results Comment References

 
The described technique of mitral valve replacement with retention of the entire subvalvular apparatus has been used in 128 patients since January 1990. The cause of mitral valve disease was myxomatous in 65, ischemic in 33, rheumatic in 25, and infectious in 5. Mechanical bileaflet valves (St. Jude Medical prosthesis; St. Jude Medical, Inc, St. Paul, MN) were implanted in 105 patients and bioprostheses were used in the remaining 23. Seventy-six patients underwent isolated mitral valve replacement with two deaths (perioperative mortality, 1.3%), 35 patients had combined mitral valve replacement and coronary artery bypass grafting with 5 deaths (mortality, 14.3%), and 1 of 17 patients undergoing multiple valve procedures died (5.9%). Echocardiographic follow-up is complete and there has been no evidence of left ventricular outflow tract obstruction or interference with prosthetic valve function by the retained subvalvular structures.

All patients have been followed up by their referring cardiologists, and in addition, 115 (90%) were interviewed by our department in February 1994 (1 to 37 months of follow-up). Preoperatively, all but 10 patients were in New York Heart Association class III or IV. At follow-up, 107 (93%) patients were in class I or II. One patient has been followed up for 22 months with a stable, small perivalvular leak.

	Comment

Top Footnotes Abstract Introduction Technique Results Comment References

 
Our technique addresses the advantages of maintaining the mitral annular-papillary muscle continuity during mitral valve replacement when valve pathology precludes repair, and avoids the potential complications of other techniques. The most dreaded complication of mitral valve operation is myocardial rupture, which is prevented by maintaining the tethering effect of the intact subvalvular apparatus [10]. The technique outlined deals with the anterior leaflet tissue to avoid left ventricular outflow tract obstruction. Transposing anterior chordal attachments to the posterior annulus can interfere with mechanical or bioprosthetic valve function [11].

We conclude that the described method to preserve the subvalvular apparatus during mitral valve replacement can be accomplished safely with acceptable operative mortality and satisfactory intermediate-term results. We hope this technique is found to be useful by others, as it is now used routinely at our institution.

	Footnotes

Top Footnotes Abstract Introduction Technique Results Comment References

 
Address reprint requests to Dr Khonsari, Regional Department of Cardiac Surgery, Kaiser Permanente Medical Center, 1526 N Edgemont St, Los Angeles, CA 90027.

	References

Top Footnotes Abstract Introduction Technique Results Comment References

 

1. Hansen DE, Sarris GE, Niczyporuk BS, Derby GC, Cahill PD, Miller DC. Physiologic role of mitral apparatus in left ventricular regional mechanics, contraction synergy and global systolic performance. J Thorac Cardiovasc Surg 1989;97: 521–33.[Abstract]
2. Gams E, Hagl S, Schad H, Heimisch W, Mendler N, Sebening F. Significance of the subvalvular apparatus for left ventricular dimensions and systolic function: experimental replacement of the mitral valve. Thorac Cardiovasc Surg 1991;39:5–12.[Medline]
3. David TE, Uden DE, Strauss HD. The importance of the mitral apparatus in left ventricular function after correction of mitral regurgitation. Circulation 1983;68(Suppl 2):76–82.[Medline]
4. Hennein HA, Swain JA, McIntosh CL, Bonaw RD, Stone CD, Clark RE. Comparative assessment of chordal preservation versus chordal resection during mitral valve replacement. J Thorac Cardiovasc Surg 1990;99:828–37.[Abstract]
5. Hetzer R, Bougioukas G, Franz M, Borst HG. Mitral valve replacement with preservation of papillary muscles and chordae tendineae: revival of a seemingly forgotten concept. Thorac Cardiovasc Surg 1983;31:291–6.[Medline]
6. Miki S, Kusuhara K, Ueda Y, Komeda M, Okita Y, Tahata T. Mitral valve replacement with preservation of chordae tendineae and papillary muscles. Ann Thorac Surg 1988;45: 28–34.[Abstract]
7. Feikes H, Daugharty J, Perry J, Bell J, Hich R, Johnson G. Preservation of all chordae tendineae and papillary muscles during mitral valve replacement with a tilting disc valve. J Cardiac Surg 1990;5:81–5.[Medline]
8. Okita Y, Miki S, Ueda Y, Tahata T, Sakai T, Matsuyama K. Replacement of chordae tendineae using expanded polytetrafluoroethylene (ePTFE) sutures during mitral valve replacement in patients with mitral stenosis. J Cardiac Surg 1993;8:567–78.[Medline]
9. Khonsari S, Sintek CF. Transatrial approach revisited. Ann Thorac Surg 1990;50:1002–3.[Abstract]
10. Okita Y, Miki S, Veda Y, Tahata T, Saki T, Matsugama K. Mitral valve replacement with maintenance of mitral annulopapillary muscle continuity in patients with mitral stenosis. J Thorac Cardiovasc Surg 1994;108:42–51.[Abstract/Free Full Text]
11. Prabhakar G, Kumar N, Hatic L, Al-Halees Z, Duran C. Accelerated failure of bioprosthesis by entrapment in chordal-sparing mitral valve replacement. J Thorac Cardiovasc Surg 1994;108:185–6.[Free Full Text]

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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 Author home page(s): Colleen F. Sintek Thomas A. Pfeffer Gary S. Kochamba Siavosh Khonsari Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Sintek, C. F. Articles by Khonsari, S. Search for Related Content PubMed PubMed Citation Articles by Sintek, C. F. Articles by Khonsari, S.