Ann Thorac Surg 2002;74:2206-2207
© 2002 The Society of Thoracic Surgeons
How to do it
Double-breasted repair of the posterior mitral valve leaflet
Jai S. Raman, MBBS, FRACSa*,
Rajiv Gupta, MBBS, MCha,
Pallav Shah, MBBS, MCha,
Ravindra Setty, MBBS, MCha,
Keiichi Tambara, MDa
a Department of Cardiac Surgery, Austin and Repatriation Medical Centre, Melbourne, Victoria, Australia
Accepted for publication June 10, 2002.
* Address correspondence to Dr Raman, Department of Cardiac Surgery, Austin and Repatriation Medical Centre, Studley Rd, Heidelberg, VIC 3084, Australia
e-mail: jai.raman{at}armc.org.au
 |
Abstract
|
|---|
The double-breasted repair of the posterior leaflet of the mitral valve is an alternative technique for correction of mitral regurgitation in selected patients. This new technique has the advantage of avoiding distortion of the posterior annulus and simplifies the repair, especially in complex posterior leaflet prolapse.
|
Introduction
|
|---|
Mitral valve repair is the ideal procedure for treating mitral regurgitation, because it preserves and utilizes the patient’s own tissues [1]. Mitral valve repair is associated with a low incidence of morbidity and has a much better track record than mitral valve replacement in terms of survival and freedom from reoperation [2]. However, there are a few complications that can occur with posterior mitral leaflet repair, the most common being abnormal systolic anterior motion of the anterior leaflet of the mitral valve [3]. Occasionally, the posterior annulus may get distorted following quadrangular resection and annular plication with injury or kinking of the circumflex coronary artery [4]. Various modifications of the original techniques promulgated by Carpentier and Duran have been reported.
We describe a simple technique which corrects mitral regurgitation while avoiding distortion of the posterior annulus and minimizing the risk of systolic anterior motion of the anterior leaflet.
|
Technique
|
|---|
A complete median sternotomy is performed through a small skin incision [5]. Aortic and bicaval cannulation is performed and the patient connected to cardiopulmonary bypass. Blood cardioplegia is administered antegrade through the aortic root and retrograde through the coronary sinus.
The mitral valve is approached through the superior, biatrial transseptal approach. The mitral valve is assessed with antegrade cardioplegia being administered. Figure 1A
is a schematic representation of the surgeon’s view of the mitral valve through the left atrium showing the flail segment of the middle scallop of the posterior leaflet with the torn chords. The flail segment subtending the torn chord is excised as a triangular section or a quadrilateral section with the wider segment along the base of the leaflet (Fig 1B). Adjacent leaflet tissue with chordal support to the edge is preserved, and sliding incisions are made close to the base of the leaflet next to the resected portion (Fig 1C). The two leaflet edges are double-breasted in such a way that the smaller or shorter remnant is folded sidewards and sutured to the base of the leaflet close to the apex of the sliding incision on the ventricular side (Fig 1D). The larger remnant is also advanced sidewards to overlap the other, and its tip is anchored close to the apex of the opposite sliding incision (Fig 1E). As a result, the posterior leaflet has a reduced height while maintaining chordal supports. The annulus geometry is unaltered. The mitral valve annulus is then reinforced by a posterior annuloplasty band (either Cosgrove or Duran type) (Fig 1E). Occasionally, the point where the posterior leaflet remnants cross each other might be a potential area of minor regurgitation. This is corrected by a single suture at the point where they cross (Fig 1E). In some instances, when the remnants of the posterior leaflet segments are asymmetric or when there is limited tissue, the double-breasting is partial. Figure 1F demonstrates this, where the smaller, asymmetric segment is sutured obliquely across the breadth of the folded-down remnant. This recreates a posterior leaflet of modest height and some mobility while preserving annular architecture.
View larger version (66K):
[in this window]
[in a new window]
|
Fig 1. The surgeon’s view of the double-breasted repair technique. (A) The flail segment of the middle scallop of the posterior leaflet with torn chordae. (B) The flail segment is excised as a triangular or quadrilateral section with the wider segment along the base of the leaflet. (C) The sliding incisions are made close to the base of adjacent leaflet tissue preserving the chordal support to the adjacent edges (a, b). (D) The two leaflet edges (a, b) are folded and advanced sidewards in opposite directions. (E, F) The two leaflet edges (a, b) are sutured to the base of the leaflet close to the apex of the sliding incision on the annulus.
|
|
The valve is tested again with antegrade aortic root cardioplegia and passive saline injection. After confirming competence of the valve, the left atrium is closed.
This type of repair is particularly useful when there is a large amount of posterior leaflet tissue with a localized flail segment or ruptured chordae. When the posterior leaflet tissue is not that redundant or when there is a very small amount of posterior leaflet tissue, double-breasting of the posterior leaflet remnants may result in a very immobile ridge of posterior leaflet tissue.
|
Comment
|
|---|
Mitral valve repair is the accepted method of treating mitral regurgitation due to degenerative mitral valve disease. Despite excellent results from multiple centers with classic techniques, there are cases and patients that remind us that distortion of the posterior annulus and systolic anterior motion of the anterior leaflet of the mitral valve occurs from time to time. While these might not be relevant or detectable in the early postcardiopulmonary bypass period, they may become clinically significant or obvious later.
We have performed the double-breasted repair in over 36 patients over the past 3 years with good results and no early mortality. All of them had none-to-trivial regurgitation intraoperatively after being weaned off cardiopulmonary bypass. Long-term results have been favorable and are being compared with a control group of patients.
For purposes of this report, two groups that had mitral reparative surgery for severe mitral regurgitation in a similar period were studied. Group 1 (n = 36 patients) underwent the double-breasted repair with annuloplasty, while group 2 (n = 26 patients) underwent standard quadrangular resection and annular plication. Follow-up was complete. All patients were reviewed clinically and echocardiographically.
There was one late death (2.8%) in group 1, and none in group 2. Prolapse of the middle scallop of the posterior mitral leaflet due to ruptured chords (26 patients or 81.25%) was the predominant cause of mitral regurgitation and, in 93% of the patients, histology was consistent with myxomatous tissue.
There were no reoperations in group 1 and three in group 2. Two patients required early reoperation and conversion to mitral valve replacement. One was due to an unacceptable level of systolic anterior motion of the anterior mitral leaflet and a high outflow tract gradient in the absence of inotrope use and a well-filled left ventricle. The other was due to dehiscence of the ring and disruption of the posterior annular plication sutures. One patient required repeat intervention 7 months postoperatively due to an elevated mitral valve gradient and functional mitral stenosis. There was no instance of significant systolic anterior motion of the anterior leaflet or left ventricular outflow tract obstruction in group 1.
The postoperative functional status was similar in both groups, a mean New York Heart Association class of 1.38 ± 0.6 in group 1 and a mean of 1.46 ± 0.58 in group 2 (p = NS). There was no significant difference in the grade of regurgitation between the group 1 patients (mean mitral regurgitation grade of 0.69 ± 0.7) and patients in group 2 (mean of 0.78 ± 0.8) (p = NS). The differences in mitral gradients between the groups were very significant. The mean transmitral gradient was 0.27 ± 0.96 mm in group 1 and 4.29 ± 3.57 mm in control group 2 (p = 0.0004). Patients in group 1 had some mobility of the neo-posterior leaflet, albeit reduced, compared with almost no movement of the posterior leaflet in group 2.
This technique may not be applicable if the posterior leaflet is small, restricted, or significantly calcified. A calcified annulus does not pose a contraindication to this technique. Indeed, in 10 patients, there was significant annular calcium requiring extensive piecemeal debridement and reimplantation of the posterior leaflet.
The double-breasted repair of the posterior leaflet of the mitral valve may have a role in repairing mitral regurgitation in patients presenting with large redundant posterior leaflets. It may also have special application in patients with fragile tissues and dominant circumflex coronary arteries [6].
|
References
|
|---|
- Carpentier A. Cardiac valve surgery—the "French correction". J Thorac Cardiovasc Surg 1983;86:323-337.[Medline]
- Lee E.M., Shapiro L.M., Wells F.C. Superiority of mitral valve repair in surgery for degenerative mitral regurgitation. Eur Heart J 1997;18:655-663.[Abstract/Free Full Text]
- Mihaileanu S., Marino J.P., Carpentier A.A., et al. Left ventricular outflow tract obstruction after mitral valve repair (Carpentier’s technique): proposed mechanisms of disease. Circulation 1988;78(Suppl 1):78-84.
- Grossi E.A., Galloway A.C., Kallenbach K., et al. Early results of posterior leaflet folding plasty for mitral valve reconstruction. Ann Thorac Surg 1998;65:1057-1059.[Abstract/Free Full Text]
- Ali I.M., El-Shanafi S., Kinley E.C., Clark V. Subtotal median sternotomy for heart surgery. Eur J Cardiothorac Surg 2000;17:255-258.[Abstract/Free Full Text]
- Gillinov A.M., Cosgrove D.M., Blackstone E.H., et al. Durability of mitral valve repair for degenerative disease. J Thorac Cardiovasc Surg 1998;116:734-743.[Abstract/Free Full Text]
Top
Abstract
Introduction
