Ann Thorac Surg 2002;74:602-605
© 2002 The Society of Thoracic Surgeons
How to do it
Repair of mitral valve billowing and prolapse (Barlow): the surgical technique
Roland Fasol, MD*a,
Katja Mahdjoobian, MDa
a IMC—International Medical Center Krems/Hollenburg, Austria
Accepted for publication March 14, 2002.
* Address reprint requests to Dr Fasol, IMC—International Medical Center Krems, Krustettnerstrasse, A-3506 Krems/Hollenburg, Austria
e-mail: rfasol{at}IMC-hospital.com
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Abstract
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Mitral valve repair in patients with mitral valve billowing and prolapse (Barlow) can be a demanding surgical procedure. A mitral valve repair method, which incorporates the complete resection of the middle scallop of the posterior leaflet, a sliding and folding plasty with the remaining lateral scallops combined with a triangular resection of the anterior leaflet and a ring-annuloplasty was developed, which maximizes predictable anatomic and physiologic efficacy of this repair and minimizes unpredictable results. A total of 37 consecutive patients underwent mitral repair with this method from 1996 to 1998, with consistently excellent results. Short-term follow-up information collected after 22.7 ± 8.6 months showed one late death and 93.0% of all surviving patients in New York Heart Association functional class I or II. There were no late reoperations and no thromboembolic, bleeding, or other complications. No patient had recurrent mitral regurgitation.
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Introduction
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Major advances in diagnosis and treatment of mitral valve billowing and prolapse have occurred since the first mention of the systolic click in 1887, which is now known to be the auscultatory marker of this type of mitral valve disease [1]. Mitral valve billowing and prolapse is commonly known as Barlow’s disease. It is considered to be present in approximately 4% to 6% of the population but has been described in as many as 17% [2]. Indications for early surgery in this group of patients with hemodynamically important regurgitation depends on whether valve repair is judged to be feasible. The prospects of a failed valvuloplasty, or the unfortunate but commonly absent knowledge of the mere fact that a successful mitral valve repair operation may be possible, influences some cardiologists and family doctors toward delaying surgery until the patient is significantly symptomatic [3]. Some surgeons report a successful reconstruction in 6% [4], and a few claim that mitral valve repair may be performed in up to 80% of such cases [5]. Our data show that mitral valve repair in patients with billowing and prolapse (Barlow) is possible in every patient, if our modified repair technique, which is streamlined and simplified, is applied. Therefore, inevitably depending on the experience of this procedure, we encourage relatively early surgery. Midterm results of this technique have been excellent.
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Technique
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Surgery was performed in ischemic cardiac arrest under cardiopulmonary bypass with moderate systemic hypothermia. The interatrial groove was incised and the right atrium dissected. With the left atrial roof exposed, the left atrial incision was carried out close to the mitral valve. A self-retaining retractor was used to expose the mitral valve. Accurate valve analysis using the two conceptual approaches, ie, functional and segmental, as advocated by Carpentier, was mandatory [6].
To reduce the significant excess tissue and to remodel the valve, in every patient a complete resection of the total middle scallop of the posterior leaflet (P2) and partial detachment of the remaining posterior scallops (P1 and P3) were performed. The simplified scheme of this concept of remodeling the posterior leaflet is shown in Figures 1A and 1B and 2B through 2D.
Plication of the annulus was followed by a combined sliding leaflet and folding plasty with both of the remaining lateral scallops (P1 and P3) to create a "new" posterior leaflet (Figs 1B and 2D). Sutures for the subsequent implantation of the annuloplasty ring are put into place before reattaching the leaflets to the annulus with a running 5-0 Péter’s suture (Péter’s Laboratoire Pharmaceutique, Bobingny, France). Subsequently, a triangular resection of the anterior leaflet (A2), the size and extent of the resection carefully matched to the extent of bulging was performed according to a technique previously described [7]: Two stay sutures are attached to the free edge of the anterior leaflet, carefully taking hold of the 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 [7]. Care is taken to save the major chordae. The prolapsing scallop of the anterior leaflet is resected (Fig 2E), and care is taken to keep clear of the anterior annulus and not to resect into the annulus. The free edges of the remaining anterior leaflet scallops are sewn using a running 5-0 Péter’s suture, which is made mildly taut and not cinched, so as to prevent corrugation of the leaflet tissue. The repair was completed by implanting an annuloplasty ring (Figs 1B and 2F). The simplified scheme of the essential concept of remodeling the prolapsed anterior leaflet, thus correcting the function of chordae tendinae, is shown in Figure 3.
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Fig 1. (A) Schematic drawing of the complete resection of the middle scallop of the posterior leaflet (P2), the triangular resection of the anterior leaflet (A2) and partial detachment of the remaining posterior scallops (P1 and P3). A portion of the annulus is plicated (point x), a combined sliding leaflet and folding plasty with both of the remaining posterior scallops (P1 and P3) performed with a running Péters suture, by reattaching the scallops in a way that point y of the leaflet meets point y of the annulus, and point x of the leaflet meets point x of the annulus. The free edges of the anterior and the posterior leaflets (between points x and z) are reapproximated with a running Péters suture. (B) Schematic drawing showing the reconstructed valve. A prosthetic annuloplasty ring is implanted to reinforce the repair.
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Fig 2. (A) Intraoperative view of a typical "Barlow valve," showing enormous hood-like bulging with significant excess tissue of all segments of the mitral valve. Specifically, the scallops A2 and P2 show a marked billowing and prolapse. (B) Complete resection of the middle scallop of the posterior leaflet (P2) and partial detachment of the remaining posterior scallops (P1 and P3) to allow a sliding leaflet as well as a folding plasty of the remaining segments P1 and P3. The points x, y, and z mark the "endpoints" of the leaflet reconstruction. (C) A portion of the annulus is plicated (point x), a combined sliding leaflet and folding plasty with both of the remaining posterior scallops (P1 and P3) performed with a running Péters suture, by reattaching the scallops in such a way that point y of the leaflet meets point y of the annulus, and point x of the leaflet meets point x of the annulus. The free edges of the posterior leaflets (between points x and z) are also reapproximated with a running 5-0 Péter’s suture. (D) Intraoperative view of the reconstructed posterior leaflet. After complete resection of the scallop P2, the remaining lateral scallops P1 and P3 form the "new" posterior mitral leaflet. Sutures for the prosthetic annuloplasty ring have been put through the annulus before reattaching the leaflets into the annulus. (E) A triangular resection of the anterior leaflet (A2) is performed, the size and extent of the resection carefully matched to the extent of bulging. Free edges of the remaining anterior scallopsA1 and A3 are reapproximated with a running 5-0 Péter’s suture. (F) Intraoperative view of the reconstructed mitral valve. A prosthetic annuloplasty ring is implanted to reinforce the repair.
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Fig 3. Schematic drawing of a "Barlow valve" indicating hood-like bulging of the anterior leaflet. The bulging of the anterior valve leaflet is "height"-corrected ( h) by a triangular resection of the segment A2, which also causes a subsequent functional correction of otherwise elongated chordae tendinae. (Ch = chordae tendineae; P = papillary muscle).
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All 37 consecutive patients (67.5% male; mean age 53.5 ± 13.1 years, range 22 to 78 years) survived repair surgery, with no perioperative mortality. Two patients had minor postoperative complications (reexploration for tamponade, and a transient neurologic event). Postoperative echocardiographic evaluation, performed before discharge on postoperative day 10, showed satisfactory valve function in all but 5 patients, who had a trivial residual regurgitation (Table 1).
Comparing the preoperative to the postoperative variables, a substantial reduction of left atrial diameter (55.4 ± 3.3 vs 46.3 ± 8.7 mm; p < 0.1%, using t test for paired samples and Wilcoxon matched-pairs signed-ranks test) and left ventricular end-diastolic diameter (64.8 ± 10.3 vs 55.2 ± 7.1 mm; p < 0.1%) was observed, indicating significant postoperative ventricular remodeling in this group of patients. Short-term follow-up information, collected in 1999 after a mean follow-up of 22.7 ± 8.6 months (10 to 39 months), was 100% complete. Follow-up information was obtained by telephone interviews with cardiologists, family physicians, and patients or their relatives. Postoperative events were categorized using the guidelines for reporting morbidity and mortality after cardiac valve operations [8]. A total of 839.9 patient-years are available for analysis. There was one late death (2.7%). This patient died 2 years after mitral valve surgery due to cardiac failure at the age of 81 years. Of all surviving patients, 93.0% were in New York Heart Association functional class I or II, with all of them describing their quality of life as "normal." There were no late reoperations and no thromboembolic, bleeding, or other complications. No patient had recurrent mitral regurgitation.
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Comment
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Mitral valve billowing and prolapse (Barlow) still remains a somewhat mysterious disease [4]. Probably because of the imprecise terminology, the frequency of progressive mitral valve regurgitation requiring subsequent surgery in patients with mitral billowing and prolapse remains hidden. On reviewing the literature it is evident that some confusion exists on mitral valve prolapse, as there is no uniform terminology and definition [9]. However, Barlow recommended accepting the concept of Carpentier and colleagues [10] of "billowing" and "prolapse," which is based on functional anatomical factors and is allowed a somewhat more precise definition of this disease. Nevertheless, the problem remains one of definition. Attempts by Carpentier and colleagues to separate Barlow’s from "fibroelastic deficiency" on histologic grounds turned out to be unsuccessful. However, we do believe that there is a gross appearance that is distinctive: all of these patients have marked billowing, largely of the anterior leaflet, associated with a systolic click. What distinguishes Barlow’s from other degenerative mitral valves is significant excess tissue. When the valve has distinct hood-like bulging of different parts of the anterior leaflet with excess tissue, and multiple bulging posterior scallops with excess tissue as well, it is reasonable to call it a "Barlow valve." We applied these entry criteria for our study. Nevertheless, there may be cases with identical histology that do not have these gross features; but in fact these are the features that make these cases different to repair.
In reviewing the literature, there is a paucity of recent reports of results for cases in which coherent surgical repair concepts or techniques for "Barlow" mitral valves were used [11]. There is no report of larger numbers of surgical patients undergoing repair for this disease. We therefore felt motivated to apply this "missing concept" to develop a simplified but successful repair for the billowing, prolapsing "Barlow valve." The sheer volume of 19,502 open heart patients in our hospital (Herz-Gefäßklinik GmbH, Bad Neustadt, Germany) between 1994 and 1998, including 1,705 mitral valve operations, allowed us to do so.
We are convinced that the essential components of repair should be for the surgeon to do as little as possible but still enough as required to achieve a competent mitral valve as physiologic result. The bulging leaflet scallops with excess tissue are corrected by our technique, and elongated chordae are likewise corrected without directly doing anything to them (Fig 3). Nevertheless, the prospects of a failed valvuloplasty, as well as the assumed prolonged time of ischemic arrest required for a repair procedure, if compared with a replacement, is still a frequent argument in favor of a straight-forward mitral valve replacement. However, the mean time of ischemic arrest of 49 ± 8 minutes in our series is not prolonged, as compared with mean cross-clamp times of 51 to 61 minutes, as described for isolated mitral valve procedures in the literature [12].
In conclusion, our data suggest that the simplicity of this repair technique allows successful mitral valve repair in every patient with billowing and prolapse (Barlow). Nevertheless, although we found a significant postoperative ventricular remodeling and no recurrent mitral regurgitation as well as no valve-related complications, longer follow-up times are mandatory to better judge long-term results.
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Acknowledgments
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The surgical procedures and collection of data for this manuscript have been performed at the Herz-Gefaess-Klinik GmbH Bad Neustadt, Germany, where the author was previously associated.
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References
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- Cuffer M., Barbillion M. Nouvelles recherches sur le bruit de galop cardiaque. Arch Gen Med 1887;19:129-149.
- Savage D.D., Garrison R.J., Devereux R.B., et al. Mitral valve prolapse in the general population. 1: Epidemiologic features: the Framingham Study. Am Heart J 1983;106:571-576.[Medline]
- Barlow J.B., Pocock W.A. The mitral valve prolapse enigma-two decades later. Mod Conc Cardiovasc Dis 1984;53:13-17.
- Penkoske P.A., Ellis F.H., Alexander S., Watkins E. Results of valve reconstruction for mitral regurgitation secondary to mitral valve prolapse. Am J Cardiol 1985;55:735-738.[Medline]
- Galloway A.C., Colvin S.B., Baumann F.G., et al. Long-term results of mitral valve reconstruction with Carpentier techniques in 148 patients with mitral insufficiency. Circulation 1988;78(Suppl I):I-97-I-105.
- Carpentier A.F., Lessana A., Reiland J.M., Belli E., Mihaileanu S., Berrebi A.J., Palsky E., Loulmet D.F. 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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- Edmunds L.H., Clark R.E., Cohn L.H., Miller D.C., Weisel R.D. Guidelines for reporting morbidity and mortality after cardiac valvular operations. J Thorac Cardiovasc Surg 1988;96:351-353.[Medline]
- Barlow J.B., Pocock W.A. Mitral valve billowing and prolapse: perspective at 25 years. Herz 1988;4:227-234.
- Carpentier A.F., Chauvaud S., Fabiani J.N., et al. Reconstructive surgery of mitral valve incompetence: ten year appraisal. J Thorac Cardiovasc Surg 1980;79:338-348.[Abstract]
- Tanaka K., Furuse A., Kotsuka Y., et al. Mitral valve repair with extensive resection of the anterior leaflet for regurgitation due to Barlow’s disease. Report of a case. Jpn Heart J 1997;38:865-868.[Medline]
- Soyer R., Bouchart F., Bessou J.P., et al. Mitral valve reconstruction: long-term results of 120 cases. Cardiovasc Surg 1996;4:813-819.[Medline]
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Abstract
Introduction
