Ann Thorac Surg 2003;75:1982-1984
© 2003 The Society of Thoracic Surgeons
How to do it
Optimal length of pericardial strip for posterior mitral overreductive annuloplasty
Antonio M. Calafiore, MDa*,
Michele Di Mauro, MDa,
Sabina Gallina, MDa,
Carlo Canosa, MDa,
Angela Lorena Iacò, MDa
a Department of Cardiology and Cardiac Surgery, University "G. D’Annunzio," Chieti, Italy
Accepted for publication October 27, 2002.
* Address reprint requests to Dr Calafiore, Division of Cardiac Surgery, "G. D’Annunzio" University, S. Camillo de’ Lellis Hospital, via C. Forlanini, 50, 66100 Chieti, Italy
e-mail: calafiore{at}unich.it
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Abstract
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Our recent experience with an autologous pericardium strip to obtain an overreducing posterior mitral annuloplasty is reported. From March 2001 to May 2002, 31 patients underwent this procedure to correct functional (n = 19) or postischemic (n = 12) mitral regurgitation. The length of the pericardium strip was always 4 cm; mean final mitral area was 2.9 cm2, with a mean gradient of 2.9 mm Hg. Eight patients underwent a stress test. Mitral area increased from 3.1 to 3.6 cm2, and the mean gradient increased from 3.1 to 5.2 mm Hg. Residual mitral regurgitation was 0.5 and, when present, remained unchanged at the end of the stress. Overreducing posterior mitral annuloplasty by using a 4-cm pericardial strip gives reproducible results and is effective in correcting functional or postischemic mitral regurgitation. Residual mitral regurgitation, when present, remains stable after stress.
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Introduction
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Autologous pericardium is often used for posterior mitral valve (MV) annuloplasty, in order to achieve an annular reduction with a flexible tissue. Generally used as a strip, its proper size is not standardized. Some authors use two fingers [1], others use the length of the anterior leaflet [2] or a Carpentier-Edwards sizer [3].
Following Bolling’s concepts of mitral overreduction in patients with functional mitral regurgitation (MR) and dilated cardiomyopathy (DCM) [4], we used shorter and shorter pericardial strips to correct MR in patients with DCM and postischemic MR, who, in our opinion, benefit from overreductive posterior annuloplasty. We found that it was not necessary to use a different sizing according to body size. Indeed, fixed pericardial length could give predictable and hemodynamically satisfying results and could be standardized independently from the patient’s body surface.
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Technique
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From March 2001 to May 2002, 31 patients underwent posterior mitral annulus overreduction using a 4-cm pericardial strip. Nineteen of them had functional MR due to DCM, and 12 had postischemic MR. Criteria for MV repair were already reported by us [5].
Transesophageal echocardiography was used to obtain some measurements related to MV. Mitral annulus size was obtained using four-chamber projection. MV area was assessed by means of the pressure half-time method [6]. Mitral regurgitation was graded from 0 (no MR) to 4 (severe MR). The exams were performed before surgery and after a mean of 3.2 ± 2.9 months. In a small group of patients (n = 8), a stress test was performed after 4.6 ± 3.5 months to evaluate, using the transthoracic echocardiography (TTE), the modification of the mitral area during exercise. After a baseline evaluation, patients performed a graded, bicycle exercise test, starting at 25 W for 6 minutes and increasing to 50 W for 2 minutes. The stress test was then stopped. A second TTE was performed. Measurements were taken after an average of three beats for patients in sinus rhythm and of five to 10 beats for those in atrial fibrillation..
A piece of autologous pericardium was harvested, treated for 15 minutes with a 0.625% gluteraldeyde solution, and then rinsed in three different baths of saline for 5 minutes each. A strip, 1 cm wide and 5 cm long, was cut, folded, and held with two Crile forceps. Four centimeters were measured with the aid of a ruler, and each of them was marked with a pen (Fig 1).
When the mitral annulus was exposed, several U stitches (12 to 16) were passed between the middle point of the posteromedial commissure and the middle point of the anterolateral commissure, using a 2/0 Ti-cron with a small needle (20 mm). Each suture starts before the end of the annulus covered by the previous suture (Figs 2, 3).
This is necessary to avoid folding of the pericardium when the sutures are tied.
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Fig 3. Intraoperative view. Several U stitches (12 to 16) are passed between the middle point of the posteromedial commissure and the middle point of the anterolateral commissure (A) to obtain, when sutures are tied, an overreduction of the mitral annulus (B).
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Besides MV repair, 7 patients had tricuspid repair, 19 had coronary bypass grafting, 5 had aortic valve replacement, 4 had ascending aorta replacement, and 3 had atrio-biventricualr pacemaker implantaion. No patient died during the first 30 postoperative days. Postoperative mitral areas and the related gradients in all the patients are shown in Table 1.
The final orifice was satisfying, as was the mean gradient. Table 2
shows the related results in the 8 patients who underwent a stress test to evaluate MV area modification during exercise. There was a slight increase in the MV area and in its mean gradient; however, the degree of MR did not change, demonstrating that the functionality of MR was abolished.
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Table 2. Mitral Valve Area Before and After Exercise (Transesophageal Echocardiography), a Mean of 4.6 ± 3.5 Months After Surgery
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Comment
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The use of pericardium for reduction of the posterior mitral annulus has some advantages. It is costless and can be easily prepared in the operating theater. Furthermore, it is flexible and maintains the physiologic movements of mitral annulus. Moreover, it can be addressed to the posterior annulus, the main target of mitral annuloplasty, as advocated by Cooley and associates and Bex and associates [7, 8]. The only technical issue is the possibility of reducing the posterior annulus more than we planned, as the pericardium can band when a suture is tied. To overcome this problem, we increased the number of sutures in such a way that each centimeter of pericardium contains three to four of them. This expedient avoids pericardium banding when sutures are tied, as the distance between the two ends of the suture is 2 mm or less.
Our choice is always directed to hypercorrect mitral valve dilation, as the purpose of mitral valve repair in dilated cardiomyopathy and in postischemic mitral regurgitation is to enhance the importance of the anterior leaflet, changing a bileaflet valve into a unileaflet one.
The length of pericardial strip we suggest using allows us to obtain reproducible results without mitral obstruction, focusing the closure mechanism on the anterior leaflet. The degree of overreduction was always correct. Under stress conditions, the MV area was not a limit to exercise tolerance. Furthermore, MR did not increase during exercise, demonstrating that the residual MR, if any, became fixed and lost the possibility to increase under effort.
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References
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- Scrofani R., Moriggia S., Salati M., Fundarò P., Danna P., Santoli C. Mitral valve remodeling: long-term results with posterior pericardial annuloplasty. Ann Thorac Surg 1996;61:895-899.[Abstract/Free Full Text]
- Borghetti V., Campana M., Scotti C., et al. Biological versus prosthetic rings: enhancement of mitral annulus dynamics and left ventricular function with pericardial annuloplasty at long term. Eur J Cardio-thorac Surg 2000;17:431-439.[Abstract/Free Full Text]
- Chotivanatapong T., Kasemsarn C., Sungkahapong V., Chaiseri P., Yosthasurodom C., Cholitcul S. Mitral valve repair with autologous pericardila ring. Asian Cardiovasc Thorac Ann 2001;9:10-13.[Abstract/Free Full Text]
- Bolling S.F., Deeb G.M., Brunsting L.A., Bach D.S. Early outcome of mitral valve reconstruction in patients with end-stage cardiomyopathy. J Thorac Cardiovasc Surg 1995;109:676-683.[Abstract/Free Full Text]
- Calafiore A.M., Gallina S., Di Mauro M., et al. Mitral valve procedure in dilated cardiomyopathy: repair or replacement?. Ann Thorac Surg 2001;71:1146-1153.[Abstract/Free Full Text]
- Holen J., Aaslid R., Landmark K., Simonsen S. Determination of pressure gradient in mitral stenosis with a non-invasive ultrasound Doppler technique. Acta Med Scand 1976;199:455-460.[Medline]
- Cooley D.A., Frazier O.H., Norman J.C. Mitral leaflet prolapse: surgical treatment using a posterior annular collar prosthesis. Cardiovasc Dis Bull Tex Heart Inst 1976;3:438-442.
- Bex J.P., Hazan E., Neveux J.Y., Mathey J. Annuloplastie mitrale et tricuspidienne sur reducteur linaire souple. Nouv Press Med 1976;5:1141-1142.
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