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Ann Thorac Surg 2004;77:729-730
© 2004 The Society of Thoracic Surgeons
a Divisione e Cattedra di Cardiochirurgia, IRCCS Ospedale Maggiore e Università degli Studi di Milano, Milan, Italy
Accepted for publication April 14, 2003.
* Address reprint requests to Dr Fundarò, Corso Vercelli, 35, 20144, Milan, Italy
e-mail: pinofundaro{at}yahoo.it
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Abstract |
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Introduction |
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Since November 2000, the technique described has been performed in 9 patients and mainly addresses the first pathophysiologic mechanism attempting to correct posterior leaflet tethering.
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Technique |
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The mitral valve is approached through a standard left atriotomy. Three stay sutures are first placed in the mitral annulus, at the two commissures and at the posterior leaflet midpoint, to optimize exposure and allow accurate valve assessment. By definition, no structural lesions of the leaflets and chordae are present in pure IMR. A scarred atrophic posterior papillary muscle may be observed (3 out of 9 patients, in our experience). Posterior annular dilation of varying degree is usually present. The portion of the posterior mitral leaflet attached to the postero-medial papillary muscle appears stretched toward the LV apex and may be difficult to mobilize. An incision is performed to detach the tethered segment of the posterior leaflet from the mitral annulus and extended to include the central portion of the posterior leaflet (Figure 1A, B). The secondary chordae are transected to increase posterior leaflet mobility, whereas basal chordae are preserved to avoid weakening of the atrio-ventricular junction. The detached portion of the mitral annulus is plicated with interrupted sutures and the resulting defect in the posterior leaflet closed with a running suture (Figure 1C). It should be noticed that, as a consequence of the adjacent plication, the defect at the base of the posterior leaflet is oriented in a radial direction. The plicated annulus is reinforced with a short Gore-Tex strip or posterior annuloplasty band (Figure 1D). Transesophageal echocardiography is routinely performed after discontinuation of cardiopulmonary bypass and showed mild or no regurgitation in all patients.
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Comment |
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Current conservative surgical approaches to IMR mainly focus on annular reduction, with or without implantation of a prosthetic ring [3–6]. However, because persisting regurgitation of varying degree is frequently observed with annuloplasty alone, a more sophisticated surgical approach to IMR appears indicated [2, 7].
In this respect, a strictly anatomic correction would imply surgical restoration of LV geometry to abolish functional IMR. It has been stated that the most important goal in repairing the valve is to reduce and fix the mitral annular dimension in the antero–posterior (septal–lateral in anatomic terms) axis [2, 8], which may be obtained by implanting stiffer rings [3]. However, these impair or completely abolish annular dynamic motion, which appears important for better preservation of LV function, especially in patients with ischemic cardiomyopathy [4].
In conclusion the procedure has been developed to restore a normal distance between the mitral valve attachments, ie, the annulus and papillary muscle tip, and modifies the anatomy at the valvular level to correct a functional disorder produced primarily by a LV lesion. More specifically, annular geometry is restored with a near-to-normal ratio between the antero–posterior and intercommissural diameters (3:4, according to Carpentier). Plication reduces the circumference of the posterior annulus and "repositions" the tethered portion of the mitral valve more anteriorly. The posterior leaflet is extended on the antero–posterior axis and reduced on the intercommissural axis, allowing better coaptation in the segment adjacent to annular plication. Finally, no occurrence of systolic anterior motion was observed. Further investigation and follow-up are warranted to validate preliminary results.
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This article has been cited by other articles:
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  M. A. Borger, A. Alam, P. M. Murphy, T. Doenst, and T. E. David Chronic Ischemic Mitral Regurgitation: Repair, Replace or Rethink? Ann. Thorac. Surg., March 1, 2006; 81(3): 1153 - 1161. [Abstract] [Full Text] [PDF]
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H. Izumoto and K. Kawazoe Technique of Posterior Mitral Valve Restoration Ann. Thorac. Surg., February 1, 2006; 81(2): 786 - 786. [Full Text] [PDF]
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M. Pocar, A. Moneta, and P. Fundaro Reply Ann. Thorac. Surg., February 1, 2006; 81(2): 786 - 787. [Full Text] [PDF]
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E. Villa, P. Fundaro, A. Moneta, and F. Donatelli Chronic Ischemic Mitral Regurgitation: Toward a Solution or Still an Enigma? Ann. Thorac. Surg., February 1, 2005; 79(2): 752 - 752. [Full Text] [PDF]
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