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Ann Thorac Surg 2003;75:298-300
© 2003 The Society of Thoracic Surgeons

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How to do it

Modified technique for mitral repair without ring annuloplasty

^a Department of Cardiothoracic Surgery, Southampton General Hospital, Southampton, United Kingdom
^b Department of Cardiothoracic Surgery, Papworth Hospital, Cambridge, United Kingdom
^c Department of Cardiology, University of the Witwatersrand, Johannesburg, South Africa

Accepted for publication June 20, 2002.

* Address reprint requests to Mr Wells, Department of Cardiothoracic Surgery, Papworth Hospital NHS Trust, Papworth Everard, Cambridgeshire, England CB3 8RE, United Kingdom
e-mail: francis.wells{at}papworth-tr.anglox.nhs.uk

	Abstract

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Mitral valve repair is the procedure of choice to correct mitral regurgitation. Most operative techniques use an annuloplasty ring to provide stability and durability to the correction. We present a modification of existing repair techniques, without the use of an annuloplasty ring, in which plication sutures allow both annular remodeling and stability. Clinical and echocardiographic follow-up in our series of 60 patients with a mean follow-up of 29 months is presented.

	Introduction

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Mitral valve repair is the procedure of choice to correct mitral regurgitation, particularly in patients with degenerative disease [1]. The most common repair technique is quadrangular resection with simple suture plication annuloplasty [2]. The use of an annuloplasty ring is recommended by most practitioners to prevent progressive postoperative dilatation of the posterior annulus [2]. However, left ventricular outflow tract obstruction is demonstrable in up to 5% to 10% of these patients secondary to abnormal systolic anterior motion of the anterior mitral leaflet [3]. There is also an additional restriction of movement of the posterior leaflets and annulus regardless of the type of ring used [4]. We describe a modification of the recognized technique, without the use of an annuloplasty ring, which allows (1) repair and realignment of the preserved posterior leaflet segments without tension, (2) reduction in the height of the posterior leaflet when this is required, and (3) stabilization of the posterior annulus with annular reduction adaptable to any potential dilatation.

	Technique

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Clinical and echocardiographic follow-up in the first 60 patients was undertaken through a series of clinics conducted specifically for the study. Patients were operated on between November 1988 and February 1999, with a mean follow-up of 29 months.

Operations are performed through a sternotomy, and cardiopulmonary bypass is established through bicaval venous return. Recognized techniques of standard myocardial protection are used with moderate systemic hypothermia at 28°C.

Once the mitral valve is exposed, intraoperative evaluation is undertaken and valve function is assessed according to Carpentier’s categories [5]. Assessment is made for the presence of annular dilatation, leaflet bodies are examined for billowing or perforations, and finally subvalvar chords are examined for rupture or elongation that may result in leaflet prolapse.

The prolapsing portion of the posterior leaflet is first resected as this gives excellent access to the anterior leaflet for any correction that it may require (Fig 1A). If excessive posterior leaflet is present, then undercutting of each side back to a place of normal height will give a better functional result and reduce the chance of systolic anterior motion (Fig 1B). Once any correction that is required for the anterior leaflet has been completed, attention is returned to the posterior leaflet and reconstitution of the annulus.

View larger version (40K): [in this window] [in a new window]   Fig 1. (A) Resection of prolapsed posterior leaflet segment along radial lines. (B) If excessive posterior leaflet is present, undercutting allows for normalization of height. (C) Horizontal mattress annular plication sutures. (D) Annulus plicated and leaflets reattached to the annulus and one another. (E) Completed modified mitral repair.

Once the plication sutures have been tied, 4-0 Prolene sutures (Ethicon) are placed through the leading and trailing edges of the posterior leaflet remnants (Fig 1D). The correct point of attachment of the posterior leaflet to the annulus can then be judged accurately and the suture through the trailing edge passed through the annulus. This suture is then run along the annulus reattaching each disconnected segment of the leaflet. A second suture is required for each undercut segment of the posterior leaflet that starts at the opposite end of the segment and is tied to the trailing edge suture where they meet. Finally, the medial edges of the posterior leaflet segments are reunited with interrupted sutures placed with the knots on the ventricular side of the leaflet so that they are out of the blood flow to reduce the risk of thrombo emboli.

The adequacy of the completed valve repair can be tested intraoperatively in the chosen manner of the surgeon (Fig 1E), and by transesophageal echocardiography toward the end of the procedure.

	Results

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No deaths occurred within 30 days of operation. There were three deaths in total, in all three the repair was deemed satisfactory at postmortem examination. Postoperative mitral regurgitation, if any, was graded as trivial, mild, mild-moderate, moderate, moderate-severe, and severe. Only approximately 10% of subjects had more than mild residual mitral regurgitation on either examination and in no subject was this considered to be more than moderate. There was a considerable improvement in the functional status of the patients, with 94% being in New York Heart Association classes I and II. Preoperative electrocardiographs had shown evidence of strain or hypertrophy in approximately 30% of subjects but this was reduced to 16% and 5%, respectively, at follow-up. No patient had repair failure requiring reoperation in this group. Assessment of posterior leaflet function found that this was reduced in 17 and fixed in 26 cases.

	Comment

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There are several potential disadvantages to the use of an annuloplasty ring. Overall annular motion may be reduced, with the middle scallop portion of the posterior annulus being effectively immobilized by both rigid and semirigid rings [4]. Inserting rings is time-consuming, and this is particularly important when trying to avoid prolonged cross-clamp times, such as when performing multiple procedures together with mitral valve repair or when the ventricle is severely impaired. The use of annuloplasty rings has negative cost implications, may result in dehiscence, and carries a risk of infection and hemolysis. The proposed benefit of using an annuloplasty ring even when a competent repair has been achieved without one is the prevention of progressive postoperative annular dilation and late repair failure. When plication sutures to the annulus are used in the method that we describe, extending virtually from commissure to commissure, a firm support is provided that may be resistant to ongoing postoperative dilatation. When considering the impact of this ringless repair it is important to distinguish its effects when compared to a simple plication, in which the majority of the annulus remains unsupported in the absence of an annuloplasty ring.

Our modified technique of mitral repair has several advantages. Placing appropriately sized larger or smaller plication suture bites to the posterior annulus, depending on the amount of annular dilation, reduces the annulus sufficiently to allow a tension-free repair to the posterior leaflet. Reconstitution of the preserved segments of the posterior mitral leaflet also occurs with correct alignment as the annulus has already been remodeled. Undercutting the residual segments when posterior leaflet height is increased reduces the incidence of systolic anterior motion.

Midterm follow-up of 60 patients operated on with our modified repair technique without a ring has demonstrated clinical and echocardiographic results that are equal or superior to other series described in the literature (mean length of follow-up 29 months; range, 3 to 124 months). Mean cardiopulmonary bypass and cross-clamp times were shorter than would be expected if an annuloplasty ring had been used. This cohort has little risk of perioperative complications, no systolic anterior motion, reasonably preserved annular and posterior leaflet function, and no or trivial regurgitation when assessed by transthoracic echocardiography in the operating room, and shows no progression at midterm follow-up. However, we do use an annuloplasty ring when gross annular degeneration or severe dilatation is present, or when an excellent result has not been achieved without a ring as determined by intraoperative assessment of the integrity of repair, as well as when the annulus requires extensive decalcification. Patients with rheumatic or ischemic mitral valve disease should also have a ring inserted as part of their mitral repair procedure.

We are aware that the current patient group was not consecutive or randomized. It is likely that a randomized study with long-term follow-up will be required to establish conclusively how any modified mitral repair technique without an annuloplasty ring compares with methods that use a ring.

	References

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1. Reul R.M., Cohn L.H. Mitral valve reconstruction for mitral insufficiency. Prog Cardiovasc Dis 1997;39:567-599.[Medline]
2. 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]
3. Jebara V.A., Mihaileanu S., Acar Cet Left ventricular outflow tract obstruction after mitral valve repair: results of the sliding leaflet technique. Circulation 1993;88(Part 2):30-34.
4. Green G.R., Dagum P., Glasson J.Retal Restricted posterior leaflet motion after mitral ring annuloplasty. Ann Thorac Surg 1999;68:2100-2106.[Abstract/Free Full Text]
5. Carpentier A. Cardiac valve surgery—the "French correction. " J Thorac Cardiovasc Surg 1983;86:323-337.[Medline]

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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): Clifford W. Barlow Eric Lim Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Barlow, C. W. Articles by Wells, F. C. Search for Related Content PubMed PubMed Citation Articles by Barlow, C. W. Articles by Wells, F. C. Related Collections Valve disease