HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

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): Joong H. Choh Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Choh, J. H. Search for Related Content PubMed PubMed Citation Articles by Choh, J. H.

Ann Thorac Surg 1997;64:271-273
© 1997 The Society of Thoracic Surgeons

---

How To Do It

Preservation of Anterior and Posterior Leaflet in Mitral Valve Replacement With a Tilting-Disc Valve

Department of Surgery, Sherman Hospital and Northern Illinois Heart Institute, Elgin, Illinois

Accepted for publication January 24, 1997.

	Abstract

Top Footnotes Abstract Introduction Technique Comment References

 
An operative technique for mitral valve replacement with preservation of chordae tendineae to both the anterior and posterior leaflets is described. The anterior mitral valve leaflet is completely detached from the annulus and divided into three to four islands of tissue, each with attached chordae tendineae. These islands are transposed under the posterior leaflet and secured with 4-0 polypropylene sutures. The posterior leaflet is completely preserved with no division or manipulation. This technique allows safe implantation of tilting-disc or bileaflet prostheses with excellent preservation of left ventricular function.

	Introduction

Top Footnotes Abstract Introduction Technique Comment References

 
See also page 273.

Although it has been demonstrated that both mitral valve leaflets contribute equally to preservation of left ventricular function after mitral valve replacement [1–4], most surgeons are reluctant to preserve the anterior leaflet when using a tilting-disc prosthesis in the mitral position because of concern about interference with the disc excursion by the retained anterior leaflet or anterior chordae tendineae. In fact, it has been suggested that a tilting-disc prosthesis not be used when the chordae are preserved [5]. However, recent reports suggest that tilting-disc valves may offer superior hemodynamics compared with bileaflet valves in the mitral position [6]. Even bileaflet mechanical mitral valves can be difficult to implant safely in the presence of a thickened, fibrosed, or calcified anterior leaflet, so such a leaflet has been frequently sacrificed [2, 3, 7]. To combat this problem, I have used a technique developed for preservation of the anterior mitral valve leaflet that allows safe implantation of the mechanical prosthesis, especially the tilting-disc valve.

	Technique

Top Footnotes Abstract Introduction Technique Comment References

 
After routine exposure of the mitral valve, the anterior mitral valve leaflet is completely detached from the annulus and the leaflet is divided and trimmed into three to four islands of tissue with the attached underlying chordae tendineae (Fig 1). These islands of leaflet tissue are transposed under the posterior leaflet between the posterior chordae and sutured into place using 4-0 polypropylene suture (Fig 2). The posterior leaflet is left undisturbed. The prosthetic valve is then secured in position in the usual fashion, generally using everting mattress sutures with pledgets on the left atrial side (Fig 3). The major orifice of the tilting-disc valve is oriented toward the septum, so that the excursion of the disc into the ventricular cavity occurs anteriorly (Fig 4).

View larger version (52K): [in this window] [in a new window]   Fig 1. . An incision is made at the base of the anterior leaflet along the attachment in the central fibrous body, the incision is carried to both sides, and the detached anterior mitral leaflet is divided into three or four islands of leaflet tissue, each with attached underlying chordae tendineae.

View larger version (63K): [in this window] [in a new window]   Fig 2. . These islands are transposed under the posterior leaflet and secured with 4-0 polypropylene mattress sutures.

View larger version (76K): [in this window] [in a new window]   Fig 3. . Multiple 2-0 sutures are placed in everting mattress technique along the entire mitral annulus.

View larger version (27K): [in this window] [in a new window]   Fig 4. . The prosthetic valve is secured with multiple everting mattress sutures along the entire annulus with pledgets on the left atrial side.

	Comment

Top Footnotes Abstract Introduction Technique Comment References

I have used this technique for mitral valve replacement in 15 patients with severe mitral regurgitation; some of these patients also had mitral stenosis. All patients had a tilting-disc valve implanted (Medtronic-Hall; Medtronic, Inc, Minneapolis, MN).

Even when the leaflet tissue is severely thickened or calcified, such as in cases of mitral stenosis of rheumatic origin, this technique can still be applied. The thickened or calcified portion of leaflet tissue can be excised or debulked, while retaining small islands of the leaflet with the attached chordae, which should be transposed under the posterior annulus. This will result in near-total excision of the leaflets, while still allowing chordal retention.

There has been no mortality in this group and no incidence of malfunction of the disc motion of the tilting-disc valve. This technique allows for safe preservation of both anterior and posterior leaflets even with the use of relatively high profile, tilting-disc valves.

	Footnotes

Top Footnotes Abstract Introduction Technique Comment References

 
Address reprint requests to Dr Choh, Elgin Cardiac Surgery, SC, 901 Center St, #307, Elgin, IL 60120.

	References

Top Footnotes Abstract Introduction Technique Comment References

 

1. David TE. Mitral valve replacement with preservation of chordae tendineae: rational and technical considerations. Ann Thorac Surg 1986;41:680–2.
2. Miki S, Kusuhara K, Ueda Y, Komeda M, Ohkida Y. Mitral valve replacement with preservation of chordae tendineae and papillary muscles. Ann Thorac Surg 1988;45:28–34.
3. Vander Salm TJ, Pape LA, Mauser JF. Mitral valve replacement with complete retention of native leaflets. Ann Thorac Surg 1996;59:52–5.[Abstract/Free Full Text]
4. Hansen DE, Cahill PD, Derby GC, Miller DC. Relative contributions of the anterior and posterior mitral chordae tendineae to canine global left ventricular systolic function. J Thorac Cardiovasc Surg 1987;93:45–55.[Abstract]
5. David TE. Preserving left ventricular function in mitral valve replacement. Cardio 1988;April:79–80.
6. Akins CW. Results with mechanical cardiac valvular prostheses. Ann Thorac Surg 1995;60:1836–44.[Abstract/Free Full Text]
7. Natsuaki M, Itoh T, Tomita S, et al. Importance of preserving the mitral subvalvular apparatus in mitral valve replacement. Ann Thorac Surg 1996;61:585–90.[Abstract/Free Full Text]
8. Feikes HL, Daugherthy JB, Perry JE, Bell JH, Hieb RE, Johnson GH. 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]

This article has been cited by other articles:

				T. Athanasiou, A. Chow, C. Rao, O. Aziz, F. Siannis, A. Ali, A. Darzi, and F. Wells Preservation of the mitral valve apparatus: evidence synthesis and critical reappraisal of surgical techniques Eur. J. Cardiothorac. Surg., March 1, 2008; 33(3): 391 - 401. [Abstract] [Full Text] [PDF]

				R. Fasol and F. Lakew Early failure of bioprosthesis by preserved mitral leaflets Ann. Thorac. Surg., August 1, 2000; 70(2): 653 - 654. [Abstract] [Full Text] [PDF]

				A. Aris and J. M. Gil Jaurena Leaflet preservation in mitral valve replacement with a tilting-disc valve Ann. Thorac. Surg., January 1, 1999; 67(1): 293 - 294. [Full Text] [PDF]

				J. H. Choh Reply Ann. Thorac. Surg., January 1, 1999; 67(1): 294 - 294. [Full Text] [PDF]

				N. Mediratta and A. W. Sosnowski Total Preservation of Subvalvular Apparatus During Mitral Valve Replacement Ann. Thorac. Surg., June 1, 1998; 65(6): 1840 - 1840. [Full Text] [PDF]

				J. H. Choh Reply Ann. Thorac. Surg., June 1, 1998; 65(6): 1840 - 1841. [Full Text] [PDF]

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): Joong H. Choh Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Choh, J. H. Search for Related Content PubMed PubMed Citation Articles by Choh, J. H.