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Ann Thorac Surg 1997;63:1805-1806
© 1997 The Society of Thoracic Surgeons

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How To Do It

Linear Segmental Annuloplasty for Mitral Valve Repair

Divisione Cardiochirurgia, Azienda Ospedaliera "G. Brotzu", Ospedale S. Michele, Cagliari, Italy

Accepted for publication January 7, 1997.

	Abstract

Top Footnotes Abstract Introduction Technique Comment References

 
A method of posterior mitral annulus remodeling is presented. The posterior annulus is divided into three segments, each segment encircled by a suture that is passed in a tourniquet. Coaptation of the leaflets can be achieved by tightening the tourniquets while the ventricle is being filled. This technique is simple and quick, avoids the use of foreign material, and requires less expertise and judgment than traditional annuloplasties.

	Introduction

Top Footnotes Abstract Introduction Technique Comment References

 
Reduction of annular size is a fundamental step in reparative operations on atrioventricular valves [1]. Remodeling of the annulus is achieved with various techniques with or without the use of prosthetic rings [2–4]. We present a technique that makes annular remodeling quick, simple, and effective.

	Technique

Top Footnotes Abstract Introduction Technique Comment References

 
After median sternotomy, a piece of pericardium is harvested and put in glutaraldehyde. Extracorporeal circulation is started after cannulation of aorta and venae cavae. Myocardial protection is achieved with moderate hypothermia and cold crystalloid cardioplegia.

The mitral valve is exposed through a conventional left atriotomy parallel to the interatrial groove, or, if exposure is difficult, through an additional vertical incision in the right atrium and interatrial septum. The mitral valve is carefully inspected, and the causes of incompetence are identified and dealt with by the appropriate surgical maneuver before remodeling of the posterior annulus [1]. If the valve is incompetent because of posterior annulus distention, only a linear segmental annuloplasty is performed.

The posterior annulus is divided into three segments. Three 2/0 polypropylene sutures with pericardial pledgets are then used to encircle each of the three segments. The first arm of the suture takes relatively deep bites of the annulus, running parallel to it, whereas the second arm takes perpendicular bites over the first arm (Fig 1). At the end of the segment the needles are cut and both arms of the suture are passed in a tourniquet, taking care to leave the over-and-over arm longer than the other (Fig 2). After completion of the three segments, annular remodeling is achieved by pulling on the threads through the tourniquets. Valve competence is tested by injecting cardioplegia while the aortic valve is made regurgitant by adding pressure with a finger. The tourniquets can be tightened or released until a satisfactory result is obtained. The valve orifice is then measured with cylindric sizers, and the short arm of the suture is tied over the long one, thus avoiding slipping of the suture line. The atriotomy is sutured and, after deairing, the operation is completed in a routine fashion. Competence of the valve is further assessed by transesophageal echocardiography after coming off bypass.

View larger version (10K): [in this window] [in a new window]   Fig 1. . Linear segmental annuloplasty. The first segment of the posterior mitral annulus is encircled with 2/0 polypropylene suture.

View larger version (19K): [in this window] [in a new window]   Fig 2. . Linear segmental annuloplasty. The three 2/0 polypropylene sutures are passed in tourniquets.

	Comment

Top Footnotes Abstract Introduction Technique Comment References

Placement of the sutures is quickly and easily performed and the use of foreign material, which is often expensive, is avoided. The three annular segments are shortened in an almost linear fashion, reducing the risk of dehiscence of unsupported sutures [5], but at the same time splinting the entire posterior annulus. Furthermore, the different segments can be selectively shortened under direct vision while the ventricle is being filled. Especially in cases with asymmetric annular distention, major or minor adjustments can be made quickly and with no difficulty to achieve the best coaptation of the leaflets. Measurement of the mitral orifice before tying of the sutures avoids the potential risk of creating mitral stenosis. Finally, in case of unsatisfactory results, the repair can be undone simply by removing the tourniquets and cutting the sutures.

Since May 1994 we used the described technique in 32 mitral valve repair operations. The patients were 25 men and 7 women (mean age, 56 years; range, 39 to 75 years). Adjunctive procedures were coronary artery bypass grafting (5 cases), aortic valve replacement (2 cases), tricuspid valve repair (De Vega technique, 3 cases), posterior mitral leaflet resection (19 cases), posterior mitral leaflet transposition onto anterior mitral leaflet (7 cases), and Kay procedure (1 case).

In all but 1 case, postoperative echocardiography at the time of hospital discharge showed a good result of the mitral valve repairs, showing only mild or no regurgitation.

All patients were anticoagulated for a minimum of 6 weeks or longer if in atrial fibrillation. Mean follow-up was 17 months. None of the patients suffered from embolic or hemorrhagic complication.

All patients were in New York Heart Association class I except 2 who were in class III. Echocardiographic assessments at 6-month follow-up showed trivial or no regurgitation in patients in New York Heart Association class I and moderate-to-severe regurgitation in patients in New York Heart Association class III.

The two failures probably originated from an insufficient assessment of the causes of mitral regurgitation in patients operated on for aortic valve replacement, in whom reduction of the posterior annulus was the only surgical procedure on the mitral valve.

We conclude that with this method annular remodeling and satisfactory coaptation of the leaflets can be achieved easily, adjustments can be made quickly, the use of expensive rings or foreign material is avoided, and the entire posterior annulus can be supported while maintaining its flexibility.

	Footnotes

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Address reprint requests to Dr Ricchi, Divisione Cardiochirurgia, Ospedale S. Michele, via Peretti, Cagliari 09131, Italy.

	References

Top Footnotes Abstract Introduction Technique Comment References

 

1. Carpentier A. Cardiac valve surgery-the "French correction." J Thorac Cardiovasc Surg 1983;86:323–37.[Medline]
2. Burr LH, Krayenbuhl C, Sutton MS, Paneth M. The mitral plication suture: a new technique of mitral valve repair. J Thorac Cardiovasc Surg 1977;73:589–95.[Abstract]
3. Salvador L, Rocco F, Ius P, et al. The pericardium reinforced suture annuloplasty: another tool available for mitral annulus repair? J Card Surg 1993;8:79–84.[Medline]
4. Salati M, Scrofani R, Santoli C. Posterior pericardial annuloplasty: a physiological correction? Eur J Cardiothorac Surg 1991;5:226–9.[Abstract]
5. Antunes MJ, Kinsley RH. Mitral valve annuloplasty: results in an underdeveloped population. Thorax 1983;38:730–6.[Abstract/Free Full Text]

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				A. Kollar, V. Kekesi, P. Soos, and A. Juhasz-Nagy Left ventricular external subannular plication: an indirect off-pump mitral annuloplasty method in a canine model J. Thorac. Cardiovasc. Surg., October 1, 2003; 126(4): 977 - 982. [Abstract] [Full Text] [PDF]

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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): Valentino Martelli Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Ricchi, A. Articles by Martelli, V. Search for Related Content PubMed PubMed Citation Articles by Ricchi, A. Articles by Martelli, V.