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Ann Thorac Surg 1995;60:1177-1185
© 1995 The Society of Thoracic Surgeons
Department of Cardiovascular Surgery and Organ Transplantation, Hôpital Broussais, Paris, and Hôpital Européen de Paris-La Roseraie, Aubervilliers, France
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Abstract |
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Methods. From October 1992 through June 1994, 137 patients aged 4 to 76 years (mean age, 49.1 years) were operated on. The main causes of mitral valve insufficiency were degenerative, 90; bacterial endocarditis, 15; and rheumatic, 13. The indication for operation was based on the severity of the mitral valve insufficiency (90 patients were in grade III or IV) rather than on functional class (60 patients were in class III or IV). At echocardiography 6 patients had normal leaflet motion (type I), 119 leaflet prolapse (type II), and 12 restricted leaflet motion (type III). Surgical repair was carried out using Carpentier techniques of valve reconstruction. In 3 patients, inadequate ring sizing was responsible for systolic anterior motion of the anterior leaflet diagnosed by intraoperative echo. The valve was replaced in 2 patients. There were three hospital deaths, no late deaths, one reoperation for recurrent mitral valve insufficiency due to chordal rupture 1 month after repair, one reoperation for atrial thrombus formation 5 months after repair, one anticoagulant-related hemorrhage, and one thromboembolic episode.
Results. Mid-term follow-up between 6 and 18 months was available in 94 patients. Echocardiography showed trivial or no regurgitation in 93.2% of the patients and minimal regurgitation in 6.8%. The average transmitral diastolic gradient was 3.55 ± 1.93 mm Hg. Left ventricular end-systolic diameter and volume decreased postoperatively, demonstrating an improved left ventricular function.
Conclusions. This preliminary experience has provided promising results and allowed us to define the indications of the Physio-Ring versus the classic ring. It has also shown that valve sizing and proper ring selection are of primary importance.
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Introduction |
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Since 1968, the date of the first prosthetic ring annuloplasty [1], more than 7,000 mitral valve repairs have been performed in our institution. The results have been associated with a high degree of predictability and long-term stability [2]. Although the prosthetic ring annuloplasty was only one among the multiple reconstructive procedures developed to correct all the lesions [3], it was indeed a key factor in the efficacy of these operations. Remodeling the annulus to its proper size and shape implies some rigidity of the prosthetic ring. This rigidity has been criticized for being a potential source of left outflow tract obstruction [4] or impaired left ventricular (LV) function [5]. Although it has been subsequently demonstrated that the ring itself was not responsible for these drawbacks [6, 7] and that the LV performance actually improved after remodeling annuloplasty [8], we wanted to study the feasibility and potential advantages of adding flexibility to the remodeling annuloplasty concept. This led to the development of a new prosthetic ring, the technique of implantation and early results of which are analyzed in this article.
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Material and Methods |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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). It conforms to the configuration of the normal mitral valve annulus during systole, with the characteristic 3:4 ratio between the anteroposterior diameter and the transverse diameter. Compared with the classic ring, the anteroposterior diameter has been slightly increased to better fit the degenerative and ischemic valvular diseases that are prevalent today. The anterior section is saddle-shaped to conform to the bulging of the aortic root. It acts as a foundation for optimal and durable posterior movement. The commissural and posterior sections exhibit a differential flexibility to make possible changes in size and shape of the annulus fibrosus during ventricular contraction. This flexible section, however, is longitudinally undeformable to avoid plication and the pursestring effect seen with the currently available flexible rings when tying the mattress sutures used to secure the ring. The Physio-Ring is constructed of Elgiloy bands separated by polyester film strips, which provide high-strength fatigue resistance and excellent spring efficiency. This combination of selective rigidity at the anterior section and selective flexibility at the posterior section is expected to give a significant reduction of stress on sutures while maintaining the annulus remodeling effect.
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. Excluded from this study were patients living in a foreign country because of the inherent difficulty of accurate follow-up, and patients who did not accept participation in this investigational study. All the other patients signed an informed consent form. They understood that the new ring effectively remodeled the annulus, as did the classic prosthetic ring, and had in addition some potential advantages resulting from its selective flexibility and saddle-shaped configuration. They were also informed that the Physio-Ring would be used only if at operation the configuration of the valve proved to be suitable.
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They show a majority of degenerative valvular diseases. Because there was no Marfan's disease in this series, valve degeneration comprised only two groups: (1) fibroelastic deficiency, a pathologic and clinical entity that has been described previously [9], and (2) Barlow's disease, characterized by excess valvular tissue and global myxoid degeneration. Extensive calcification of the mitral valve annulus was present in 12 cases (8.5%). The indications for operation were based on the severity of the mitral valve insufficiency (90 patients had grade III or IV) rather than on New York Heart Association functional class (60 patients were in class III or IV).
Valve Analysis
Accurate valve analysis was achieved by TM echocardiography before the operation, and by transesophageal echocardiography and visual inspection during the operation. Two conceptual approaches were used: (1) the functional classification already described in previous publications [3, 9] and (2) segmental valve analysis. In segmental valve analysis, the valvular apparatus is separated into eight segments (Fig 2). The three scallops of the posterior leaflet are identified as P1 (anterior scallop), P2 (middle scallop), and P3 (posterior scallop). The three corresponding segments of the anterior leaflet are termed A1 (anterior part), A2 (middle part), and A3 (posterior part). The remaining two segments are the anterior commissure and the posterior commissure. These 8 segments are analyzed comparatively using P1 as the reference point [10] because leaflet prolapse is rare at this level. The free edges of the other seven segments are compared with P1 to recognize and measure occasional prolapse. Leaflet pliability is also explored at each segment. This segmental valve analysis provides precise information, which serves as a guideline to valve reconstruction. For example, a type II, A3 P3 indicates a prolapse (type II) of both the posterior scallop (P3) and the corresponding posterior part of the anterior leaflet (A3), two prolapses that must be corrected. A combined type II A2, type IIIa P3 indicates a localized prolapse (II) of the middle part of the anterior leaflet (A2) associated with a restricted opening (IIIa) of the posterior scallop (P3) of the posterior leaflet; the anterior leaflet prolapse needs to be corrected and the restricted posterior leaflet motion requires leaflet mobilization. This method of valve analysis makes it possible, before operation, to classify the mitral valve dysfunctions (Table 2), to assess the feasibility of the repair, and to predict the techniques to be used (Table 3).
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APPROACH.
In the past 6 years, we have been using the following interatrial approach, which was first demonstrated during the 1988 Le Club Mitrale sessions (Fig 3). Two cannulas are used to drain the blood from the venae cavae. Those vessels are surrounded by tapes. The interatrial groove is incised and the two atria are dissected and divided up to the fossa ovalis. With the roof of the left atrium widely exposed, the left atrial incision is carried out very close to the mitral valve, approximately 3 to 4 cm from the classic left atrial incision. Two blades of a self-retaining retractor are then used to expose the mitral valve. This approach has provided excellent exposure even when a small atrium was present.
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). Various sizers are tried, and the one whose intercommissural distance (between the two notches) corresponds to that of the annulus is selected. Using the same sizer, the height of the anterior leaflet is then measured. The anterior leaflet is unfurled by gentle downward traction on the marginal chords using nerve hooks, and the sizer is placed so as to cover the unfurled leaflet. The free edge of the leaflet must not extend more than 1 mm beyond the inferior edge of the sizer. In most cases, a good correlation between the width and the height of the anterior leaflet is found. If this is not the case, a classic ring is preferred, the vertical diameter of which can be enlarged by bending upward the free ends of the ring until its vertical diameter corresponds to the height of the anterior leaflet (Fig 5). During this study, a classic ring was the preferred choice in 9 patients (9/137; 6.5%) because of an abnormally high anterior leaflet.
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). They have been described in previous publications [3, 6, 10]. Of particular importance is to make sure that no excess tissue of the mural leaflet has been left in place, another potential cause of SAM. Whenever the height of the valvular remnants of the posterior leaflet is greater than 1 cm, the excess leaflet tissue must be resected or plicated using the sliding leaflet technique [2, 6]. The associated cardiac procedures carried out in this series were as follows: |
Results |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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Complications
Table 4 summarizes the complications encountered in this experience. A SAM was diagnosed by intraoperative transesophageal echocardiography in 3 patients. Because of the unknown significance and fate of the resulting ventriculoaortic gradient, the valve was replaced in 2 patients who had a gradient of more than 30 mm Hg. In 1 patient with a ventriculoaortic gradient of less than 30 mm Hg, the ring was left in place and both the gradient and SAM disappeared within 4 months. A recurrent mitral valve insufficiency was observed in 1 patient 30 days after valve repair. The cause was rupture of the chords of the anterior leaflet arising from the posterior papillary muscle. Chordal abrasion, due to improper placement of the sutures that were used to close the trench of the papillary muscle after chordal shortening, was most probably the cause of this complication. Finally, 1 patient had a thrombus in the left atrial appendage. The patient was reoperated on and the thrombus was removed.
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). Echocardiography over 6 months was obtained in 73 patients at 6 months and 56 patients at 12 months. Although the ring orifice area varied from 325 to 722 mm2 (Table 6), a minimal diastolic gradient averaging 3.5 ± 1.93 mm Hg was noted, which surprisingly tended to diminish over a period of 1 year (Table 7). At 6 months, 93.2% of the patients had no residual mitral valve regurgitation, and at 12 months, it was 94.7%. Mild regurgitation was observed in 6.8% and 5.3% of the patients after 6 and 12 months, respectively (Table 8). With the exception of the patient who required a reoperation 30 days after valve repair (0.7%), none of the patients had severe or moderate residual or recurrent mitral regurgitation. End-diastolic diameters and volumes and end-systolic diameters and volumes of the LV returned to normal after the operation (Fig 6).
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Comment |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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). Thus, in our institution, although fewer than 5% of the mitral valve insufficiency cases could be repaired in the early 1970s, the percentage was 25% in the 1980s, and more than 70% in the 1990s. In 1976, seven years after the introduction of the ring annuloplasty concept and most of the reconstructive procedures, Duran and colleagues [18] proposed the use of a totally flexible ring with the aim of retaining a more normal systolic motion of the mitral annulus. The same year, Cooley and associates [19] introduced a horseshoe ring, very similar to Belcher's posterior reinforcement, to avoid sutures at the anterior leaflet, but this technique was abandoned after few years because of the increased fragility associated with noncircumferential supports.
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Left Outflow Tract Obstruction and Systolic Anterior Motion
Some years ago, our group carefully analyzed the mechanism producing postrepair SAM of the mitral valve and the risk factors involved [7]. The main two reasons were excess tissue of the posterior leaflet (Fig 8) and inadequate ring sizing, resulting in too small a ring for a too large anterior leaflet. The latter was the cause of the 3 cases of SAM observed in this series, because the mural leaflet had been reduced in size in all of these 3 cases using the sliding leaflet technique [6]. Of these 3 cases, 1 with a moderate gradient was not reoperated on, whereas the 2 others with a gradient greater than 30 mm Hg were reoperated upon. The valve could have been repaired a second time in these cases by using a larger ring. However, the policy in this investigational series was to replace the valve whenever such a problem occurred. As experience grew, the technique of valve sizing was refined as described in this article, and no case of SAM was seen in the last 56 patients. On the other hand, it is interesting to note that in the patient who was not reoperated on, SAM and ventriculoaortic gradient disappeared after 4 months, a common finding whenever SAM is seen with a limited gradient [6, 7].
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). These contradictory findings between different well-documented experimental and clinical works point out the difficulty in analyzing and interpreting perturbed regional LV geometry and ventricular function whenever the changes are limited, the more so because the plasticity of the myocardium plays a significant role in smoothing out these changes. On the other hand, the clinical results do not always correlate with sophisticated measurements and theoretical considerations. For example, in David and colleagues' comparative clinical series of flexible versus rigid rings, no complications were seen in the rigid ring group, whereas 2 of 14 patients (15%) in the Duran ring group ``experienced serious postoperative complications: one patient was kept on ventilator for 15 days and the other required a reoperation in the third postoperative week because of paravalvular mitral regurgitation'' [5]. The reasons we introduced the Physio-Ring were not so much that we believe in the superiority of flexible rings over rigid rings in term of hemodynamics (we have not yet been able to find a statistically significant difference in LV function between this series and our previous series using the classic ring [2]), but rather the fact that a flexible structure may reduce the stress on the sutures and therefore may further reduce the incidence of residual or recurrent mitral valve insufficiency, particularly in complex cases [24–28].
Mitral Valve Function
The low incidence of residual mitral valve insufficiency in this series was particularly striking. It seems lower than our previous figures using the rigid ring. Reviewing the long-term results in a consecutive series of 151 patients, Deloche and associates [2], from our group, found 74% of patients free from regurgitation at 13 years, whereas 10% had 1+ mitral regurgitation, 7.3% 2+, and 2.5% 3+. Indeed, it is not possible to compare two series of patients with such a difference in follow-up. However, Deloche and associates pointed out that two thirds of the residual mitral valve insufficiencies were present within the first year after the operation, for an incidence of 17% versus 12% in this series. The low transvalvar gradient may explain in part the low incidence of thromboembolism in this series, which contrasts sharply with the higher incidence reported in series in which narrowing annuloplasties with totally flexible and deformable rings or ``adjustable'' rings were used [29, 30]. In a series of 85 patients reviewed after 10 to 12 years, Duran and co-authors [29] found a 20.1% incidence of thromboembolic complications for a linearized rate of 2.52%/patient-year [29]. This correlates with a reduced mean valve orifice area of 1.93 ± 0.74 cm2, which contrasts with the 3.55 cm2 mean orifice area found in our series. Although it may be questionable to compare the results of different patient populations, recognizing in particular that Duran and co-authors' series comprised a large number of rheumatic valvular disease cases, differences of this magnitude must have some significance. We believe that not only the overnarrowing effect but also the pursestring effect with irregular contour of the totally flexible ring were the main causes of this higher rate of thromboembolism.
In conclusion, the results of this series have been promising so far. However, if the Physio-Ring represents a conceptual advance in mitral valve annuloplasty because it combines remodeling and flexibility, only longer follow-up will evaluate precisely its benefit over the classic annuloplasty ring.
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Address reprint requests to Dr Carpentier, Cardiovascular Surgery Department, Hôpital Broussais, 96, rue Didot, 75014 Paris, France.
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C.-K. Ng, C. Punzengruber, O. Pachinger, J. Nesser, H. Auer, H. Franke, and P. Hartl Valve repair in mitral regurgitation complicated by severe annulus calcification Ann. Thorac. Surg., July 1, 2000; 70(1): 53 - 58. [Abstract] [Full Text] [PDF]
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V. Borghetti, M. Campana, C. Scotti, D. Domenighini, P. Totaro, G. Coletti, M. Pagani, and R. Lorusso Biological versus prosthetic ring in mitral-valve repair: enhancement of mitral annulus dynamics and left-ventricular function with pericardial annuloplasty at long term Eur. J. Cardiothorac. Surg., April 1, 2000; 17(4): 431 - 439. [Abstract] [Full Text] [PDF]
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A. M. Gillinov, D. M. Cosgrove III, T. Shiota, J. Qin, H. Tsujino, W. J. Stewart, J. D. Thomas, M. Porqueddu, J. A. White, and E. H. Blackstone Cosgrove-Edwards Annuloplasty System: midterm results Ann. Thorac. Surg., March 1, 2000; 69(3): 717 - 721. [Abstract] [Full Text] [PDF]
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G. R. Green, P. Dagum, J. R. Glasson, J. F. Nistal, G. T. Daughters II, N. B. Ingels Jr, and D. C. Miller Restricted posterior leaflet motion after mitral ring annuloplasty Ann. Thorac. Surg., December 1, 1999; 68(6): 2100 - 2106. [Abstract] [Full Text] [PDF]
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G. R. Green, P. Dagum, J. R. Glasson, G. T. Daughters, A. F. Bolger, L. E. Foppiano, G. J. Berry, N. B. Ingels Jr, and D. C. Miller Mitral Annular Dilatation and Papillary Muscle Dislocation Without Mitral Regurgitation in Sheep Circulation, November 9, 1999; 100 (2009): II-95 - II-102. [Abstract] [Full Text] [PDF]
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 R. M. Savage and D. M. Cosgrove Systematic Transesophageal Echocardiographic Examination in Mitral Valve Repair: The Evolution of a Discipline into the Twenty-First Century Anesth. Analg., June 1, 1999; 88(6): 1197 - 1197. [Full Text] [PDF]
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A.-S. Lambert, J. P. Miller, S. H. Merrick, N. B. Schiller, E. Foster, I. Muhiudeen-Russell, and M. K. Cahalan Improved Evaluation of the Location and Mechanism of Mitral Valve Regurgitation with a Systematic Transesophageal Echocardiography Examination Anesth. Analg., June 1, 1999; 88(6): 1205 - 1205. [Abstract] [Full Text] [PDF]
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J. R. Glasson, G. R. Green, J. F. Nistal, P. Dagum, M. Komeda, G. T. Daughters, A. F. Bolger, L. E. Foppiano, N. B. Ingels Jr, and D. C. Miller MITRAL ANNULAR SIZE AND SHAPE IN SHEEP WITH ANNULOPLASTY RINGS J. Thorac. Cardiovasc. Surg., February 1, 1999; 117(2): 302 - 309. [Abstract] [Full Text] [PDF]
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L. F. Camilleri, B. Miguel, P. Bailly, B. J. Legault, M.-C. D'Agrosa-Boiteux, G. L. Polvani, and C. M. de Riberolles Flexible posterior mitral annuloplasty: five-year clinical and Doppler echocardiographic results Ann. Thorac. Surg., November 1, 1998; 66(5): 1692 - 1697. [Abstract] [Full Text] [PDF]
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J.-F. G. Fuzellier, S. M. Chauvaud, P. Fornes, A. J. Berrebi, P. S. Lajos, P. Bruneval, and A. F. Carpentier Surgical management of mitral regurgitation associated with marfan's syndrome Ann. Thorac. Surg., July 1, 1998; 66(1): 68 - 72. [Abstract] [Full Text] [PDF]
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D. F. Loulmet, A. Carpentier, P. W. Cho, A. Berrebi, N. d'Attellis, C. B. Austin, J.-P. Couetil, and P. Lajos Less invasive techniques for mitral valve surgery J. Thorac. Cardiovasc. Surg., April 1, 1998; 115(4): 772 - 779. [Abstract] [Full Text] [PDF]
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A. Dall'Agata, M. A. Taams, P. M. Fioretti, J. R. T. C. Roelandt, and L. A. Van Herwerden Cosgrove-Edwards Mitral Ring Dynamics Measured With Transesophageal Three-Dimensional Echocardiography Ann. Thorac. Surg., February 1, 1998; 65(2): 485 - 490. [Abstract] [Full Text] [PDF]
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E. M. Lee, L. M. Shapiro, and F. C. Wells Midterm Results of Mitral Valve Repair With the Sculptor Annuloplasty Ring Ann. Thorac. Surg., May 1, 1997; 63(5): 1340 - 1345. [Abstract] [Full Text]
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 J. B. Barlow, R. H. Kinsley, S. R. Fetscher, M. Enriquez-Sarano, and J. Ross Mitral Regurgitation Due to Flail Leaflet N. Engl. J. Med., May 1, 1997; 336(18): 1322 - 1324. [Full Text]
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A. F. Carpentier, M. Pellerin, J.-F. Fuzellier, and J. Y. M. Relland EXTENSIVE CALCIFICATION OF THE MITRAL VALVE ANULUS: PATHOLOGY AND SURGICAL MANAGEMENT J. Thorac. Cardiovasc. Surg., April 1, 1996; 111(4): 718 - 730. [Abstract] [Full Text]
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