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Ann Thorac Surg 1996;61:895-899
© 1996 The Society of Thoracic Surgeons

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Original Articles: Cardiovascular

Mitral Valve Remodeling: Long-Term Results With Posterior Pericardial Annuloplasty

Divisions of Thoracic and Cardiovascular Surgery and Cardiology, Ospedale ``L. Sacco,'' Milan, Italy

Accepted for publication November 19, 1995.

	Abstract

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Background. We studied the long-term results of a technique of mitral annuloplasty using autologous pericardium.

Methods. Between June 1989 and December 1994, 113 mitral valvuloplasties were performed for myxomatous degenerative disease. Repair of isolated anterior leaflet prolapse was performed in 26 patients (23%), posterior leaflet prolapse in 38 (33.6%), and prolapse of both leaflets in 49 (43.4%). Posterior pericardial annuloplasty was performed in all patients. In 20 patients, the pericardial graft was marked with metal clips for postoperative cinefluoroscopic assessment of annulus motion.

Results. The operative mortality rate was 2.7% (3/113). One patient died of a myocardial infarction and 2 of low cardiac output syndrome. One patient required replacement of the mitral valve 2 days after operation because of dehiscence of the annular plication. Follow-up (average length, 32.41 ± 20.09 months; range, 1 to 71 months) was 97% complete and revealed good clinical and functional results: 95 patients (84.1%) were in New York Heart Association class I and had no regurgitation or only mild residual regurgitation. Postoperative transmitral flow indices were almost normal (mitral valve area = 3.7 ± 0.4 cm²; peak flow velocity = 1.06 ± 0.2 m/s). Only 3 patients had reoperation within 3 years (actuarial 5-year reoperation-free rate, 89.7%) and event-free survival at 5 years was 91%. In patients with metal clips marking autologous pericardium, planimetry of the area derived by fluoroscopic examination showed systolic narrowing of annulus size (8.5% ± 6.4%; p < 0.01) and a slight systolic fall in the anteroposterior diameter of the annulus contour (5.9% ± 3.8%; p < 0.01).

Conclusions. Posterior pericardial annuloplasty seems to be a safe, effective, and easily performed technique and a more physiologic correction that preserves mitral annulus motion.

	Introduction

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Prosthetic annuloplasty rings are currently used in mitral reconstruction. Recently, flexible rings have been introduced to preserve mitral annulus function [1–3]. In 1991, we [4] reported a technique for remodeling of the posterior mitral valve annulus using autologous pericardium. The purpose of this study was to evaluate long-term results in patients who underwent mitral valve repair with this technique.

	Material and Methods

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Between June 1989 and December 1994, 113 consecutive patients underwent an open heart operation for mitral regurgitation caused by myxomatous degenerative disease. Autologous pericardium was used for the posterior annuloplasty in all patients. Sixty-eight patients were men and 45, women; the mean age was 58.1 ± 12.09 years (range, 22 to 84 years). Seven patients (6.2%) were in New York Heart Association class IV, 78 (69.0%) were in class III, 24 (21.2%) were in class II, and 4 (3.5%) were in class I. Forty-seven patients (41.6%) were in chronic atrial fibrillation.

Echocardiographic Evaluation
All patients underwent two-dimensional echocardiographic examination before operation, at the time of discharge from the hospital, and then yearly. Chamber size was obtained from M-mode findings. The grade of mitral regurgitation was evaluated by means of the ratio between the regurgitant jet area and the left atrial area: values ranging from 0% to 20% were considered grade 1; between 20% and 40%, grade 2; and higher than 40%, grade 3 [5]. The mitral valve area was measured both by the half-time pressure method and by short-axis planimetry. Transmitral flow characteristics were defined in terms of peak velocity and mean velocity. Preoperatively, all patients had severe (grade 3+) mitral incompetence. Isolated anterior leaflet prolapse was observed in 26 patients (23%), posterior leaflet prolapse in 38 (33.6%), and prolapse of both leaflets in 49 (43.4%).

Operative Technique
After sternotomy and before aortic and caval cannulation, the pericardium was opened longitudinally. A strip of pericardium (0.5 to 0.6 cm x 5 to 6 cm) was freed of adipose and extrapleural tissue, treated with a 10-minute immersion in 0.0625% glutaraldehyde solution, and rinsed in physiologic solution. In the first 20 patients, metal clips were attached to the midline of the external surface of the pericardial strip. The marked strip was rolled up in a tubular fashion with the serosal surface outside. Moderate systemic hypothermia (28°C) and cold cardioplegia were employed for myocardial protection. The mean aortic cross-clamp time was 71 ± 18 minutes.

Posterior leaflet prolapse was managed by a wide quadrangular resection (38 patients). Anterior or bilateral leaflet prolapse was treated by quadrangular resection of the posterior leaflet and transposition of the chordae to the anterior leaflet (75 patients). The annulus beneath the excised or transposed portion of the mural leaflet was plicated with interrupted stitches (2-0 polyester). The procedure was completed by closing the residual cleft of the mural leaflet with interrupted sutures. The pericardial graft was placed along the posterior annulus just beyond the anatomic commissures, fixed with mattress sutures (4-0 polyester), and spaced to restrict the posterior annulus. The optimal diameter of the annulus was determined, stitch by stitch, by digital control, so as to obtain an orifice measuring two fingerbreadths. Myocardial revascularization was performed in 12 patients (10.6%) and a De Vega annuloplasty for functional tricuspid regurgitation, in 11 patients (9.7%).

All patients were placed on a regimen of anticoagulant therapy for 3 months postoperatively. Then they were switched to antiplatelet therapy.

Fluoroscopy
In the 20 patients whose pericardial strip had the metal clips, cinefluoroscopic recordings at 50 frames per second were obtained in the left anterior oblique projection 10 days after operation and then at 1 year and 5 years. Systolic and diastolic annulus contours, displayed by the metal clips, were entered into a computer, and the respective areas were calculated by means of suitable software. The distance between the posterior annulus and the midpoint of the line joining the two commissures was recorded and assumed to be the anteroposterior radius.

Statistical Analysis
All data are expressed as the mean ± the standard deviation. The paired t test was used to compare the results before and after operation. Fisher's exact test and the life-table method were used when appropriate.

	Results

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Clinical Results
There were three hospital deaths (2.7%). One patient died suddenly 4 days after operation of posterior papillary muscle rupture caused by intraoperative myocardial infarction, and 2 patients died of low cardiac output syndrome. One patient required early reoperation for severe mitral regurgitation caused by dehiscence of the annular plication. Myocardial infarction occurred in 2 patients and gastric hemorrhage in 1 patient. No patient experienced thromboembolism or endocarditis during the postoperative course.

At a mean postoperative interval of 32.41 ± 20.09 months (range, 1 to 71 months), follow-up was 97% complete. Ninety-five patients (84.17%) were in New York Heart Association functional class I or II. Three patients died during follow-up (1 of aortic dissection, 1 of renal failure, and 1 of gastric cancer).

Three patients had reoperation within 3 years. The condition of 1 patient deteriorated slowly because of associated aortic regurgitation, and double-valve replacement was performed after 51 months. The other 2 patients underwent reoperation after 12 and 18 months because of unsatisfactory mitral repair. Freedom from reoperation at 1 year and 5 years was 97% and 89.7%, respectively (Fig 1). At reoperation, each pericardial prosthesis appeared completely endothelialized and was indistinguishable from the atrial endocardium. No evidence of calcification was observed. A sample of pericardium was taken from 1 patient for histologic study (Fig 2), which revealed only a mild inflammatory reaction.

View larger version (10K): [in this window] [in a new window]   Fig 1. . Five-year freedom from reoperation for patients who underwent mitral valvuloplasty.

View larger version (146K): [in this window] [in a new window]   Fig 2. . Photomicrograph of histologic section of autologous pericardium. There is no evidence of calcification, and only a mild, aspecific inflammatory reaction is present. (Hematoxylin and eosin; x10 before 44% reduction.)

View larger version (10K): [in this window] [in a new window]   Fig 3. . Five-year freedom from events (death, thromboembolism, reoperation, myocardial infarction, endocarditis, and anticoagulation-related hemorrhage) for patients who underwent mitral valvuloplasty.

View larger version (44K): [in this window] [in a new window]   Fig 4. . Comparison between (A) left ventricular end-diastolic diameter and (B) end-systolic diameter measurements and various degrees of residual mitral regurgitation (MR). There are no significant differences, even in patients with moderate residual MR. See Echocardiographic Evaluation section for MR grading.

	Comment

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
In the surgical repair of mitral incompetence, annuloplasty is performed for four reasons: (1) to correct the dilatation of the annulus, (2) to increase the leaflet coaptation, (3) to reinforce the annulus sutures when part of the valve has been resected, and (4) to prevent future dilatation of the annulus. Stabilization of the posterior annulus with a ring or other type of support seems important for the reinforcement of the posterior leaflet and creates a buttress against which the anterior leaflet can open and close [6–9].

In deciding what type of annuloplasty to use, a complete understanding of the function of the mitral annulus is essential. The mitral annulus is an elliptic portion of a hyperbolic paraboloid (``saddle shape'') and it has a sphincterlike function that reduces the area by approximately 26% during systole [10]. During the cardiac cycle, it changes its shape-becoming circular during diastole and elliptic in systole. These changes in size and shape result from relaxation and contraction of the basoconstrictor muscles [11, 12]. In patients with degenerative mitral regurgitation, dilatation of the annulus involves only the posterior mitral annulus, as the anterior portion of the mitral annulus is part of the fibrous skeleton of the heart. Our aim was to restore a normal annulus shape by selectively shortening the annulus segments that had been dilated by the pathologic process with a technique that best preserves the physiologic contractile properties of the mitral annulus.

In the first part of our experience (73 patients), the usual valvuloplasty procedures [3] were associated with a selective posterior annuloplasty performed with a conduit of expanded polytetrafluoroethylene. Since 1989, we have substituted autologous pericardium for the polytetrafluoroethylene conduit to obtain a softer prosthesis that conforms to the natural geometry of the annulus [13, 14]. The efficacy of this technique is demonstrated by our clinical results (postoperative New York Heart Association class I or II, 84.1% of patients, and 5-year reoperation-free rate, 89.7%) and echocardiographic results. Postoperative sequential Doppler echocardiographic studies showed that most patients (84.1%) had mild or no mitral regurgitation at the late postoperative studies and significant reduction in left ventricular dimensions. Even in the 17 patients (15.0%) with moderate mitral regurgitation postoperatively, there was a significant fall in left ventricular end-diastolic diameter, and, more important, the left ventricular dimensions were unchanged after 12 months. Only 1 (5.9%) of them needed mitral valve replacement after reconstruction because of progression of mitral regurgitation, but this patient had associated aortic valve regurgitation that probably contributed to the repeat dilatation of the annulus. The other patients with moderate mitral regurgitation did not exhibit a clinically significant increase in the severity of mitral valve insufficiency during follow-up, a finding indicating that autologous pericardium is strong enough to prevent dilatation of the annulus.

In our experience, no patient exhibited left ventricular outflow tract obstruction. This abnormality, which is due to systolic anterior motion of the mitral valve, has been described as a complication of rigid-ring annuloplasty, and the reported incidence ranges from 4.5% to 10% [15–18]. Systolic anterior motion has been described in only 1 patient having annuloplasty without a rigid ring [19]. We believe that confining the annuloplasty to the posterior portion of the annulus and using a pliable annulus graft are effective in avoiding systolic anterior motion.

The method of preserving autologous pericardium is extremely important in determining tissue durability and preventing calcification. The scientific procedure of using autologous tissue treated with a brief immersion in glutaraldehyde solution was established by Chauvaud and colleagues in 1991 [20]. On the basis of this experimental study, the clinical use of glutaraldehyde-pretreated pericardium became established in our institution for all mitral valve reconstructive procedures. In our experience, we have observed no evidence of calcification or tearing of the pericardial graft; no instance of calcification was detected in our 113 patients followed by echocardiographic evaluation, and this result was confirmed by microscopic examination of autologous pericardium from 1 patient (see Fig 2).

Pericardium has been attractive to the cardiac surgeon for a long time. Its ready availability, its ease of handling, and its pliability make it an obvious choice when a defect must be eliminated. We believe that there is sufficient evidence to support the use of autologous pericardium, as its long-term durability and low thrombogenicity offer several advantages. The benefits conferred by autologous tissue, the easily accomplished surgical technique, the effective functioning of the remodeled valve, and the preservation of the natural shape of the valve make this technique a useful surgical alternative for extensive mitral valve reconstructive procedures.

	Footnotes

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Address reprint requests to Dr Scrofani, Divisione di Chirurgia Toracica e Cardiovascolare, Ospedale ``L. Sacco,'' Via G. B. Grassi n. 74, 20157 Milano, Italy.

	References

Top Footnotes Abstract Introduction Material and Methods 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 Author home page(s): Stefano Moriggia Pino Fundaro Carmine Santoli Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Scrofani, R. Articles by Santoli, C. Search for Related Content PubMed PubMed Citation Articles by Scrofani, R. Articles by Santoli, C.