Ann Thorac Surg 2004;77:1103-1104
© 2004 The Society of Thoracic Surgeons
How to do it
Leaflet folding plasty combined with annular plication for mitral valve repair
Masato Nakajima, MDa*,
Kouji Tsuchiya, MDa,
Hidenori Inoue, MDa,
Kensuke Kobayashi, MDa,
Eiki Mizutani, MDa,
Koki Takizawa, MDa
a Department of Cardiovascular Surgery, Yamanashi Central Hospital, Kofu City, Yamanashi, Japan
Accepted for publication May 12, 2003.
* Address reprint requests to Dr Nakajima, Department of Cardiovascular Surgery, Yamanashi Central Hospital, 1-1-1 Fujimi, Kofu City, Yamanashi 400-0027, Japan
e-mail: m-nakajima2a{at}ych.pref.yamanashi.jp
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Abstract
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We describe a new technique of mitral valve repair based on two reconstructive techniques: (1) the folding leaflet method, and (2) the classic annular plication. This combination appears to be useful in cases with a large prolapsing posterior mitral leaflet with excessive leaflet height or in cases with commissural prolapse involving both the anterior and posterior leaflets.
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Introduction
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Leaflet folding plasty was introduced by Grossi and colleagues [1] to avoid systolic anterior motion and circumflex coronary arterial injury after reconstruction of the posterior mitral leaflet with a large annular plication. We combined this technique with classic annular plication and McGoon's [2] leaflet plasty. The usefulness of this combination for reconstruction of large prolapsing posterior mitral leaflet with excessive leaflet height or commissural prolapse involving both anterior and posterior leaflet is described.
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Technique
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After induction of general anesthesia, transesophageal echocardiography is routinely used for preoperative and postrepair evaluation of the mitral valve. Through a median sternotomy, standard cardiopulmonary bypass is instituted with bi-caval venous cannulation and ascending aortic return, and the left heart venting through the right upper pulmonary vein. Under ventricular fibrillation, the left atrium is incised on the posterior interatrial groove, extending posteriorly beneath both caval veins. Mitral valve analysis is performed carefully as described by Carpentier [3], including determination of the prolapsing leaflet, the annular dilatation, and the location of the jet lesion. After antegrade cold blood cardioplegic arrest is obtained, the mitral valve is repaired using the folding leaflet technique with annular plication, as described as follows. In addition, prosthetic ring annuloplasty is performed in all patients.
A large posterior mitral leaflet that is prolapsing due to chordal rupture or elongation with excessive leaflet height is resected into a quadrangular shape (Figs 1a, 1b). The length of the annulus and the leaflet remaining after leaflet resection are carefully evaluated. The vertical cut edge of both sides of the posterior leaflet are folded down and anastomosed to the annulus leaving a symmetrical leaflet length (Fig 1c). If the lengths of the cut edges on the two leaflets are different, they are adjusted by unilateral folding plasty. After the folding plasty, annular plication with McGoon's [2] leaflet plasty and prosthetic ring annuloplasty are performed (Fig 1d).
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Fig 1. (a) Prolapsing posterior mitral leaflet due to chordal rupture with excessive leaflet height. (b) Quadrangular resection of the prolapsing leaflet. The black arrows indicate the direction to fold. (c) Folding plasty leaving a symmetrical cut edge. (d) McGoon's [2] annular plication and prosthetic ring annuloplasty.
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A leaflet that exhibits commissural prolapse due to commissural chordal rupture or elongation is carefully resected into a trapezoid shape, including both redundant anterior and posterior leaflets (Fig 2a, 2b). The length of the cut edge on the anterior leaflet is longer than that of the posterior leaflet in almost all cases; therefore only the vertical cut edge of the anterior leaflet needs to be folded down on the annulus in order to make the leaflet length symmetrical (Fig 2c). After the folding plasty is done, commissural annular plication and prosthetic ring annuloplasty are performed (Fig 2d).
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Fig 2. (a) Prolapsing commissural leaflet due to chordal rupture. (b) Resection of prolapsing leaflet including both anterior and posterior leaflets. The black arrow indicates the direction to fold. (c) Folding plasty of cut edge of anterior leaflet leaving symmetrical commissural defect. (d) McGoon's [2] annular plication and prosthetic ring annuloplasty.
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Results
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From October 1997 to July 2003, 8 patients with mitral regurgitation underwent mitral valve repair using leaflet folding plasty combined with annular plication. Five patients had large prolapsing posterior mitral leaflets with excessive leaflet height, and 3 patients had commissural prolapse involving both the anterior and posterior leaflets. The patient group was comprised of 5 men and 3 women whose mean age was 58.6 years (range, 41 to 73 years). All patients had myxomatous valve disease. Concomitant procedures included ring annuloplasty in all patients and coronary artery bypass grafting in 1 patient. Operation time, cardiopulmonary bypass time, and aortic cross-clamp time were 194 ± 28, 95 ± 8.3, and 60 ± 5.7 minutes, respectively. There were no hospital deaths, and early postoperative echocardiogram showed no residual regurgitation in any patients. There were no findings of systolic anterior motion and existence of pressure gradient on the left ventricular outflow tract in all patients with posterior leaflet repair, and there was no sign of valve restriction in patients with commissural repair. Mean follow-up period was 32 months (range, 6 to 66 months). All patients were in good hemodynamic condition at follow-up, and no reoperations were required.
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Comment
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Leaflet folding plasty was introduced by Grossi and colleagues [1] to avoid systolic anterior motion and circumflex coronary arterial injury after reconstruction of the posterior mitral leaflet with a large annular plication [4]. This folding plasty was equally able to prevent the incidence of systolic anterior motion due to anterior displacement of the posterior ventricular wall as was the sliding leaflet technique [5]. Furthermore, by lowering the posterior leaflet height when a large posterior plication is performed, folding plasty is considered to be more effective in comparison with the sliding leaflet technique and is more beneficial with regard to the simplicity of the reconstructive process after resection of the diseased leaflet. We combined this technique with classic annular plication and McGoon's [2] leaflet plasty. This combination was simple, useful, and widely applicable to reconstruction of the large prolapsing posterior mitral leaflet with excessive leaflet height. That is, we can flexibly control the height of the posterior leaflet and adjust the asymmetrical length of the corresponding cut edge by controlling the folding length. In a case requiring complicated shaped leaflet resection, folding the leaflet so as to create a symmetrical quadrangular shape makes the repair simpler.
In cases of commissural prolapse involving both the anterior and posterior leaflet, technical difficulty still remains. Previously described techniques for repairing large commissural prolapse are based on the sliding leaflet technique with modifications such as cusp remodeling by counterclockwise sliding, commissural reflection, and extended leaflet sliding [6–8]. These are effective techniques; however, they require a long incision of the normal leaflet with suture mobilization. Our combination method resolves these technical difficulties, because reconstruction is needed only in the resected areas. In other words, our method requires neither an additional incision nor a complicated suture reconstruction. In cases with restricted anterior mitral leaflet and small annular size, postoperative valve restriction and reduced effective orifice area due to commissural plication should be mentioned.
We consider the combination of our folding leaflet plasty with annular plication to be a simple and effective procedure in cases with redundant anterior mitral leaflet, but of limited value in cases with restricted anterior mitral leaflet and small annular size.
As this is a small series of patients with a limited postoperative follow-up period, the further follow-up should be required for examining long-term durability of this repair.
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References
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- 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]
- McGoon D.C. Repair of mitral insufficiency due to ruptured chordae tendineae. J Thorac Cardiovasc Surg 1960;39:357.
- Carpentier A. Cardiac valve surgery – the "French correction". J Thorac Cardiovasc Surg 1983;86:323-327.[Medline]
- Spencer F.C., Galloway A.C., Grossi E.A., et al. Recent developments and evolving techniques of mitral valve reconstruction. Ann Thorac Surg 1998;65:307-313.[Abstract/Free Full Text]
- Jebara V.A., Mihaileanu S., Acar C., et al. Left ventricular outflow tract obstruction after mitral valve repair. Results of the sliding leaflet technique. Circulation 1993;88(Part 2):30-34.
- Sutlic Z., Schmid C., Borst H.G. Repair of flail anterior leaflets of tricuspid and mitral valves by cusp remodeling. Ann Thorac Surg 1990;50:927-930.[Abstract]
- Dreyfus G., Serraf A., Jebara V.A., et al. Valve repair in acute endocarditis. Ann Thorac Surg 1990;49:706-713.[Abstract]
- Van Herwerden L.A., Taams M.A., Bos E. Repair of commissural prolapse by extended leaflet sliding. Ann Thorac Surg 1994;57:387-390.[Abstract]
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Abstract
Introduction
