Ann Thorac Surg 1999;68:261-262
© 1999 The Society of Thoracic Surgeons
How to Do It
Use of the anterior mitral leaflet to reinforce the posterior mitral annulus after debridement of calcium
Filip P. Casselman, MDa,
A. Marc Gillinov, MDa,
Monica L. McDonald, MDa,
Delos M. Cosgrove, III, MDa
a Department of Thoracic and Cardiovascular Surgery, The Cleveland Clinic Foundation, Cleveland, Ohio, USA
Address reprint requests to Dr. Gillinov, Department of Thoracic and Cardiovascular Surgery, The Cleveland Clinic Foundation/Desk F25, 9500 Euclid Ave, Cleveland, OH 44195
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Abstract
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In mitral valve surgery, preservation of continuity between the papillary muscles, chordae, and annulus is associated with preservation of left ventricular function and reduced risk of postoperative left ventricular rupture. However, at mitral valve replacement, extensive annulus and leaflet calcification can necessitate resection of the posterior mitral leaflet. We describe a technique in which the anterior mitral leaflet and its subvalvular apparatus are used to reinforce the posterior mitral annulus after extensive debridement of calcium along the same annulus.
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Introduction
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Although mitral valve repair is the preferred technique to correct mitral regurgitation of all etiologies, extensive annulus calcification can preclude repair. Elderly women and young patients with connective tissue disorders [1] can have extensive calcification of the posterior mitral annulus extending onto the posterior leaflet and subvalvular apparatus; in this situation, adequate debridement can necessitate resection of the posterior mitral leaflet and valve replacement.
At mitral valve replacement, preservation of the posterior mitral leaflet and its subvalvular apparatus results in improved postoperative left ventricular function and outcome [2, 3] and is considered a preventive technique against postoperative left ventricular rupture [4, 5]. Therefore, efforts to preserve all or part of the mitral valve and subvalvular apparatus should be undertaken at mitral valve replacement. We describe a technique for preservation of the anterior mitral leaflet and its subvalvular apparatus and use of these structures to reinforce the posterior annulus after resection of a calcified posterior mitral leaflet and extensive annular debridement.
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Technique
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The mitral valve is exposed through a left atriotomy or transseptal approach (Fig 1). The calcified annulus is carefully debrided with pituitary rongeurs, and the affected portions of the posterior leaflet are resected. The chordae tendineae are transected at the level of the papillary muscle heads. To "fill" the defect left after leaflet resection and debridement of the posterior annulus, the anterior mitral leaflet is detached from the annulus (Fig 2). This leaflet is then transferred to the posterior annulus and positioned to fill the defect in the posterior mitral annulus. Subsequently, supraannular pledgeted valve sutures are placed in the anterior mitral annulus. At the level of the posterior mitral annulus, the sutures pass underneath the translocated leaflet and thereby fix it to the posterior annulus (Fig 3). The remaining part of the valve replacement procedure is standard (Fig 4).
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Fig 2. View of mitral valve after debridement. The posterior leaflet is resected, and the remaining posterior mitral annulus is irregular. The broken line indicates the zone of detachment of the anterior mitral leaflet from the corresponding annulus.
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Fig 3. The anterior mitral leaflet is now transferred: pledgeted sutures are placed in the posterior mitral annulus or what remains after debridement. These sutures anchor the transferred anterior mitral leaflet by passing underneath it.
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Comment
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Several techniques have been proposed to deal with the calcified mitral annulus and its reconstruction after debridement [6–9]. These include use of autologous pericardium, ultrasonic debridement, sliding atrioplasty, and patch-glue reconstruction. Each of these techniques reinforces the posterior mitral annulus, thus providing secure tissue for seating of a prosthetic valve.
The technique described here uses autologous tissue to cover the area of debridement. The anterior leaflet is generally larger than the posterior leaflet and therefore provides more tissue to buttress the area of debridement. The resultant preservation of continuity between the annulus and subvalvular apparatus may enhance postoperative left ventricular function and reduce the incidence of left ventricular rupture [4, 5]. This technique has been used successfully to reinforce an area of extensive debridement in 20 patients. None of these patients sustained left ventricular rupture.
Modifications of this technique could also be used to repair posterior left ventricular rupture after mitral valve repair. Indeed, similar use of the posterior mitral leaflet to repair such a rupture has been proven useful in this setting [10].
In conclusion, we present a technique for transfer of the anterior mitral leaflet and its subvalvular apparatus to reconstruct the posterior mitral annulus after debridement. This technique is simple and reproducible and provides potential advantages in preservation of left ventricular function and prevention of left ventricular rupture after mitral valve replacement.
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Acknowledgments
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We thank Jeffrey J. Loerch for the medical illustrations.
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References
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Accepted for publication January 14, 1999.
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Abstract
Introduction
