Ann Thorac Surg 2001;71:381-383
© 2001 The Society of Thoracic Surgeons
How to do it
Triangular resection of the anterior leaflet for repair of the mitral valve
Roland Fasol, MDa,
Elrina Joubert-Hübner, CTPb
a Herz- und Gefaess-Klinik GmbH, Bad Neustadt, Germany
b IMC—International Innovative Medical Care Center, Krems, Austria
Accepted for publication May 20, 2000.
Address reprint requests to Dr Fasol, International "Innovative Medical Care" Center, Josef-Steininger Platz 2, A-3550, Gobelsburg, Austria
e-mail: rfasol{at}heart-surgeon.com
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Abstract
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Isolated anterior mitral leaflet prolapse, unlike posterior prolapse, is a difficult lesion to repair and may become a demanding surgical procedure. We report our experience with a technique of a triangular resection of the anterior leaflet to repair isolated segmental anterior leaflet prolapse in 18 patients. This technique simplifies the repair procedure and is a safe and rapid procedure which allows excellent results.
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Introduction
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To repair the mitral valve is considered to be the procedure of choice and it seems to be generally accepted to be preferable to mitral replacement. However, isolated segmental prolapse of the anterior leaflet with subsequent significant mitral regurgitation is, unlike a posterior prolapse, a pathology not often observed, and surgery of such patients may become a challenge. Some authors prefer the extensive use of artificial chordae [1] or the transposition of posterior or secondary chordae [2]. Others advocate the bow-tie repair, a simple edge-to-edge suture to create a double orifice, when the anterior leaflet is prolapsed [3]. Observations of abnormal bulging of the bodies of mitral valve leaflets let Criley and colleagues introduce the term "prolapse" in 1966 [4]. The term "billowing" may be appropriate, when the physiologic, slightly bulging of normal mitral leaflets into the left atrium after closure is exaggerated [5]. However, to attack the isolated prolapse of the anterior leaflet by resection of some parts is opposed by many and advocated by few. We report our experience of repairing isolated anterior leaflet prolapse by a triangular resection. Midterm results of this technique have been excellent.
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Technique
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After achieving cardiac arrest, the interatrial groove is incised and the right atrium dissected. With the left atrial roof exposed, the left atrial incision is carried out close to the mitral valve. A self-retaining retractor is used to expose the mitral valve. Accurate valve analysis using the two conceptual approaches, the functional and segmental approach, as advocated by Carpentier and coworkers [6], is postulated to be mandatory. The common situation of patients where an isolated triangular resection of the anterior leaflet is performed is a degenerative mitral valve with a significant segmental prolapse of one or more of the three scallops of the anterior leaflet (A1–3). The simplified scheme of the concept of remodeling the prolapsed anterior leaflet by a triangular resection is explained in Figure 1. Figure 2A demonstrates the prolapse of a lateral segment of the anterior leaflet (A1), and Figure 3A demonstrates the prolapse of the middle segment of the anterior leaflet (A2). Two stay 4.0, nonabsorbable sutures are attached to the free edge of the anterior leaflet, carefully grabbing major chordae, to delineate the area involved. Furthermore, cold saline is carefully instilled into the left ventricle to help visualize the prolapse and the area of resection (Fig 3A). Care is taken to save major chordae. The prolapsing scallop of the anterior leaflet is resected, and care is taken to keep clear of the anterior annulus and not to resect into the annulus (Fig 2B, 3B). Following the triangular resection, the free edges of the remaining anterior leaflets are sewn using a running 5.0 Peter’s suture (Peter’s Laboratoire Pharmaceutique, Bobingny, France) (Figs 1A, 2B). Deep bites are taken through the leaflet tissue, providing additional tissue to buttress the suture line, which is particularly helpful if the leaflet tissue is thin. Furthermore, the suture is placed and made mildly taut, though not excessively and not cinched, so as to prevent corrugation of the leaflet tissue. The repair procedure is completed by the implantation of a Carpentier-Edwards "physio-ring" (Fig 1B).
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Fig 1. (A) Schematic drawing of a mitral valve, indicating isolated segmental prolapse with a hood-like bulging of this part of the anterior leaflet. The prolapsing scallop of the anterior leaflet is resected using the technique of a triangular resection. Care is taken to keep clear of the anterior annulus and not to resect into the annulus. (B) The free edges of the remaining anterior leaflet scallops are sewn using a running 5.0 Peter’s suture, which is made mildly taut and not cinched, so as to prevent corrugation of the leaflet tissue. The repair procedure is completed by the implantation of an annuloplasty ring.
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Fig 2. (A) Intraoperative view of a mitral valve showing the isolated segmental prolapse of the lateral scallop (arrow), close to the commissure. (B) The prolapsing scallop of the anterior leaflet is removed by a triangular resection, and the free leaflet edges are sewn by a running 5.0 Peter’s suture.
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Fig 3. (A) Intraoperative view demonstrating the prolapse of the middle segment of the anterior mitral leaflet (A2). (B) Triangular resection removed the prolapsing scallop of the anterior leaflet, and the free edges of the remaining anterior leaflet scallops (A1 and A3) are to be sewn.
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Comment
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Anterior leaflet prolapse may be repaired with different techniques. At present, it seems that three methods enjoy some sort of acceptance: implantation of artificial chordae [7], transposition of chordae [2], and Alfieri’s technique of a bow-tie repair, creating a double orifice mitral valve [3]. However, results of creating a double orifice mitral valve by a simple edge-to-edge suture may be hampered if isolated anterior leaflet prolapse is present with a huge billowing due to significant excess tissue (Fig 3A). To repair this type of mitral regurgitation by the implant of a number of artificial chordae or by the transposition of chordae may be a simple and straightforward, as well as reproducible, technique. However, those patients with extensive myxomatous disease and excessive leaflet tissue are prone to developing abnormal systolic anterior motion and left ventricular outflow obstruction. This complication may occur in 4% to 10% of patients undergoing mitral valve repair procedures [8].
The technique described here, a segmental triangular resection of the prolapsing leaflet scallop, is an alternative and simple way of repairing isolated anterior mitral valve leaflet prolapse. The bulging leaflet scallops with excess tissue are easily corrected by this technique. The running suture, using the "semi-flexible" 5.0 Peter’s suture, permits quick and effective leaflet remodeling.
Between January 1998 and May 1999, out of a total of 530 mitral operations, with a percentage of 63% repair procedures (339 patients), this simplified technique of a triangular resection of the anterior leaflet was used in 18 patients (5.3%) having isolated mitral repair for degenerative disease. All 18 patients had successful mitral repair, there was no hospital death, no failures requiring replacement have occurred, and there was no instance of left ventricular outflow obstruction due to systolic anterior motion. Postoperative echocardiographic evaluation, performed shortly before discharge on postoperative day 10, showed satisfactory valve function in all but 2 patients, who had a trivial residual regurgitation.
This technique of triangular resection of isolated segmental anterior leaflet prolapse may be an important contribution to the various tools and techniques of mitral valve repair surgery.
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References
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Sousa U.M., Grare P., Jebara V., et al. Transposition of chordae in mitral valve repair. Mid-term results. Circulation 1993;88(Suppl II):35-38.
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Criley J.M., Lewis K.B., Humphries J.O., Ross R.S. Prolapse of the mitral valve: clinical and cine-angiocardiographic findings. Br Heart J 1966;28:488-496.[Free Full Text]
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Carpentier A.F., Lessana A., Reiland J.M., et al. The "physio-ring": an advanced concept in mitral valve annuloplasty. Ann Thorac Surg 1995;60:1177-1186.[Abstract/Free Full Text]
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Abstract
Introduction
