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Ann Thorac Surg 1998;65:1057-1059
© 1998 The Society of Thoracic Surgeons

Early Results of Posterior Leaflet Folding Plasty for Mitral Valve Reconstruction

^a Division of Cardiothoracic Surgery, Department of Surgery, New York University Medical Center, New York, New York USA

Accepted for publication November 10, 1997.

Address reprint requests to Dr Grossi, Department of Surgery, New York University Medical Center, 530 First Ave, Suite 9V, New York, NY 10016
e-mail: (grossi{at}cv.med.nyu.edu)

	Abstract

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Background. Standard reconstruction for posterior mitral leaflet (PML) disease is quadrangular resection and annular plication; when the PML is excessively high, a sliding plasty is used. We have developed an alternative technique, a posterior leaflet folding plasty. It is performed by folding down the cut vertical edges of the PML. The central height of the PML is reduced, leaflet coaptation is moved posteriorly, and annular plication is unnecessary.

Methods. From March 1995 to August 1996, 26 (17.9%) of 145 patients undergoing mitral reconstruction had a posterior leaflet folding plasty. Concomitant procedures included anterior leaflet resection or resuspension and myotomy and myectomy. In 3 patients, the PML resection extended to a commissure.

Results. There was one death and no reoperations. The mean New York Heart Association class was improved from 2.4 preoperatively to 1.4. There was no major postoperative mitral insufficiency in the 26 patients. Systolic anterior motion was transiently seen in 1 patient in whom left ventricular outflow tract obstruction was present preoperatively.

Conclusions. The data demonstrate the safety and short-term efficacy of posterior leaflet folding plasty. This technique may help avoid systolic anterior motion after reconstruction of the PML.

	Introduction

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The standard operative technique for correcting a prolapsing posterior mitral leaflet (PML) includes quadrangular leaflet resection and annular plication to bring the cut edges into apposition [1]. The cut leaflet edges are anastomosed, and an annuloplasty ring is placed to reinforce the repair. This technique corrects the prolapsing defect and maintains or slightly advances the line of closure between the anterior and posterior leaflets toward the anterior annulus.

There are two anatomic situations, however, in which this technique can cause problems. First, when redundant anterior leaflet tissue and a high posterior leaflet are present, there is a predisposition to systolic anterior motion (SAM) of the anterior mitral leaflet and the potential for left ventricular outflow tract obstruction [2]. This situation can result because the standard repair technique does not lower the posterior leaflet height and indeed, may slightly advance the line of leaflet coaptation toward the anterior annulus when a large posterior plication is performed. The second anatomic situation of concern occurs when a large circumflex artery is present in the atrioventricular groove (eg, left dominant coronary circulation). A large posterior annulus plication in this situation can injure the circumflex artery by kinking it (Fig 1).

View larger version (169K): [in this window] [in a new window]   Fig 1. Angiogram showing obstruction (arrow) of a circumflex marginal artery after a large posterior leaflet resection and annular plication. This obstruction was recognized intraoperatively and corrected with a bypass graft.

View larger version (19K): [in this window] [in a new window]   Fig 2. (A) Prolapsing posterior mitral leaflet with excessive leaflet height. (B) Quadrangular resection of prolapsing posterior segment. Points a and b will be brought down to common point c on posterior annulus. Note that no annular plication is required. (C) Result of symmetric folding plasty with cut edges of posterior leaflet sutured down to annulus and suture closure of posterior "neocleft."

View larger version (19K): [in this window] [in a new window]   Fig 3. (A) Large prolapsing posterior mitral leaflet with excessive leaflet height. (B) Quadrangular resection of prolapsing posterior segment involving most of posterior annulus. Point a is brought to a' and b, to b'. Annular plication is performed between points a' and b'. (C) Resultant reconstruction of symmetric folding plasty with small posterior annulus plication.

	Material and methods

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View larger version (16K): [in this window] [in a new window]   Fig 4. (A) Prolapsing posterior mitral leaflet with excessive leaflet height and extension up to posteromedial commissure. (B) Resection of prolapsing leaflet up to commissure. Point a is brought to a'. Note that there is no need for annular plication. (C) Asymmetric folding plasty with cut edge of posterior leaflet sutured down to annulus extending up to commissure.

	Results

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	Comment

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The incidence of SAM after mitral reconstruction is less than 5% [3, 4]. It remains challenging, however, for the surgeon to recognize the predisposing anatomic circumstances and to employ reparative techniques that minimize the risk of SAM. A billowing anterior leaflet with excessive tissue in conjunction with a large posterior annulus plication appears to best characterize the subset of patients at highest risk for perioperative SAM. Echocardiographic studies have revealed that SAM occurs after anterior displacement of the posterior ventricular wall, narrowing of the mitral-aortic angle, and end-diastolic placement of the mitral leaflets in the subaortic "outflow" region [2]. During systole, closure of the posterior leaflet pushes the anterior leaflet into the left ventricular outflow tract, thereby causing a dynamic obstruction [5].

When excessive PML height exists, Carpentier [6] proposed that a sliding plasty repair technique be used in which the base of the PML is resected. Reducing the PML allows more posterior excursion of the anterior mitral leaflet and may reduce SAM [5]. This technique, however, does require a posterior annuloplasty as part of the reconstruction to bring leaflet edges into apposition. Although this technique is generally effective, SAM with severe left ventricular outflow tract obstruction has been observed even after this procedure [7].

We have developed an alternative method with distinct advantages for reconstructing the PML in the presence of excessive tissue height. With the PLFP, the need of a posterior annulus plication is obviated or greatly reduced. Eliminating annular plication prevents anterior displacement of the posterior wall and its subsequent pathophysiologic events. In addition, the folding plasty moves the line of leaflet coaptation posteriorly, thus lessening the likelihood of "pushing" the anterior leaflet into the outflow tract. Even with the PLFP technique, however, we have thought it necessary to perform an anterior triangular leaflet resection [8] to complete the reconstruction in 38.5% of these patients.

The hallmark of a mitral reconstruction performed with Carpentier’s spectrum of repair techniques is long-term durability. The PLFP adheres to the principles of supporting the leaflet tissue, eliminating tension on the leaflet suture lines, and reinforcing the reconstruction with an annuloplasty ring. The short-term results with our alternative method for posterior leaflet repair are at least as good; it is reasonable to expect that longer-term results will prove similarly successful. It is important to note that the PLFP technique avoids annular plication, reduces posterior leaflet height, and shows excellent freedom from SAM. A larger patient series with longer follow-up will be necessary to statistically document the overall efficacy of PLFP compared with previously used methods for preventing SAM.

	References

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1. Carpentier A. Cardiac valve surgery—the "French correction". J Thorac Cardiovasc Surg 1983;86:323-327.[Medline]
2. Mihaileanu S., Marino J.P., Chauvaud S., et al. Left ventricular outflow obstruction after mitral valve repair (Carpentier’s techniques): proposed mechanisms of disease. Circulation 1988;78(Suppl 1):I78-I84.
3. Grossi E.A., Steinberg B.M., LeBoutillier M., III, et al. Decreasing incidence of systolic anterior motion after mitral valve reconstruction. Circulation 1994;90(Suppl 2):195-197.[Abstract/Free Full Text]
4. Grossi E.A., Galloway A.C., Colvin S.B., et al. Experience with 28 cases of systolic anterior motion (SAM) after Carpentier mitral valve reconstruction. J Thorac Cardiovasc Surg 1992;103:466-470.[Abstract]
5. Jebara V.A., Mihaileanu S., Acar C., et al. Left ventricular outflow tract obstruction after mitral valve repair: results of the sliding leaflet technique. Circulation 1993;88(Suppl 2):30-34.
6. Carpentier A. The sliding leaflet technique. Le Club Mitrale Newsletter 1988;1:2-3.
7. Lee K.S., Stewart W.J., Savage R.M., Loop F.D., Cosgrove D.M., III Systolic anterior motion of mitral valve after the posterior leaflet sliding advancement procedure. Ann Thorac Surg 1994;57:1338-1340.[Abstract]
8. Grossi E.A., Galloway A.C., LeBoutillier M., et al. Anterior leaflet procedures during mitral valve repair do not adversely influence long-term outcome. J Am Coll Cardiol 1995;25:134-136.[Abstract]

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This Article Abstract Full Text (PDF) 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): Eugene A. Grossi Aubrey C. Galloway Klaus Kallenbach Jeffrey S. Miller Rick Esposito Daniel S. Schwartz Stephen B. Colvin Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Grossi, E. A. Articles by Colvin, S. B. Search for Related Content PubMed PubMed Citation Articles by Grossi, E. A. Articles by Colvin, S. B.