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Ann Thorac Surg 1996;62:1250-1252
© 1996 The Society of Thoracic Surgeons
Department of Cardiovascular Surgery, Bursa Yuksek Ihtisas Hospital, Bursa, Turkey
To the Editor:
We read with great interest the wonderful article entitled "Mitral Valve Replacement With Complete Retention of Native Leaflets" by Dr Vander Salm and colleagues [1] and the related letter by Dr Banerjee and associates [2]. Inspired by their easy and reproducible technique we tried to employ leaflet preservation by reefing the native leaflets with horizontal mattress sutures, but encountered a relative drawback of the technique, and solved the problem with a simple modification.
The patient was a 38-year-old woman complaining of dyspnea on exercise, appreciated as New York Heart Association class III. She was still in sinus rhythm and had a loud pansystolic murmur over her entire chest and a history of rheumatic fewer. A severe mitral regurgitation, mild pulmonary hypertension and left ventricular enlargement was disclosed upon echocardiographic examination. On March 8, 1996, the patient underwent an open heart operation. The mitral valve revealed annular enlargement, the posterior leaflet was extremely thickened and retracted, and there was severe chordal elongation on the anterior leaflet. Mitral valvuloplasty seemed improbable, and we decided to perform prosthetic valve replacement with complete retention of the leaflets.
While applying Teflon felt pledget-reinforced horizontal mattress sutures through the anterior leaflet annulus as described [1], we noticed a strong tendency to upward plication of the leaflet tissue, which would have been a bulky mass impinging toward the atrial side at the completion of the replacement (Fig 1
). The recess between the plication and the atrial wall might have acted as a thromboembolic focus by causing stasis and containing Teflon pledget at the nadir of that concavity, and the plication itself could have directly impeded the prosthetic function. So we converted to wrapping up the leaflets with an interrupted over-and-over suturing technique, as in our previous posterior leaflet preservations (11 cases of unpublished data). In this method, we began suturing from the left atrial side, passing through the mitral annulus, around the mitral leaflet, and again through the mitral annulus from the atrial side. To wrap up the leaflet by encircling it with the loop, the needle was once again brought up around the mitral leaflet (Fig 2). The arms of each suture were attached with surgical clamps and compiled together and, after the sutures to the mitral annulus were entirely completed, appropriate prosthetic size was assessed and the needles were then passed through the prosthetic annulus of a no. 29 Carpentier-Edwards pericardial tissue valve (the patient's preference) (Baxter Healthcare, Santa Ana, CA) proportionally. Sliding over the stretched sutures, the prosthesis was inserted to its bed and tied down. The retained subvalvular elements were examined carefully and seemed not to impede prosthetic valve function.
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), there was no ventriculo-aortic gradient, subvalvular elements were visualized to be well preserved, and prosthetic valve function was normal with a trivial atrioventricular gradient (mean, 5 mm Hg).
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To draw a general conclusion based on a single case that does not even have long-term follow-up might be inappropriate, but the technique described herein appears to be a safe, effective, and simple means of complete retention of native leaflets in mitral valve replacement in suitable cases.
References
Division of Thoracic and Cardiac Surgery, University of Massachusetts Medical Center, 55 Lake Ave N, Rm 53-751, Worcester, MA 01655-0304
To the Editor:
Doctor Sezer and colleagues have correctly identified a possible difficulty with the procedure my colleagues and I described [1], and have imaginatively resolved it. Rather than using horizontal mattress sutures, which allowed the native valve to create a bulky mass above the annulus, they used figure-of-8 or over-and-over sutures to confine the redundant anterior leaflet. These same sutures were then used to secure the prosthetic valve.
The figure-of-8 suture is, in fact, the one taught to me when I was learning to perform valve replacements. I eventually abandoned it because of the increased strength of the horizontal mattress suture, and the decreased incidence of paravalvular leaks. However, in the instance of leaving all valvular tissue intact, this technique described by Dr Sezer and associates should give excellent purchase for the sutures against the remaining bulk of the folded mitral leaflets. I congratulate them on their ingenuity.
Since the publication of our article, I too have encountered the same problem but have solved it in a different fashion. In those patients who have had excessive (and usually thickened) anterior leaflet, I have excised a crescent from the leaflet, leaving the primary chordae intact, much as has been described by David for the posterior leaflet [2]. This also results in the elimination of excessive anterior leaflet being extruded out between the prosthetic and tissue annuli. I am grateful to Dr Sezer and associates for adding one more weapon to our armamentarium.
References
This article has been cited by other articles:
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  J. F. Obadia, C. Casali, J. F. Chassignolle, and M. Janier Mitral Subvalvular Apparatus : Different Functions of Primary and Secondary Chordae Circulation, November 4, 1997; 96(9): 3124 - 3128. [Abstract] [Full Text]
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