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Ann Thorac Surg 2004;78:564-568
© 2004 The Society of Thoracic Surgeons

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Original article: cardiovascular

Anterior leaflet augmentation for ischemic mitral regurgitation

^a Department of Cardiothoracic Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA

Accepted for publication February 10, 2004.

^* Address reprint requests to Dr Kincaid, Department of Cardiothoracic Surgery, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157, USA
e-mail: tkincaid{at}wfubmc.edu

	Abstract

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BACKGROUND: Mitral valve repair improves survival and quality of life in patients with ischemic mitral regurgitation (MR). Although many repair methods exist for this condition, the ideal approach remains unknown. The purpose of this study is to describe a simple technique for repair of ischemic MR that addresses the pathophysiology of tethered leaflets and to report its early results.

METHODS: The technique consists of pericardial patch enlargement of the anterior mitral leaflet and placement of a flexible annuloplasty band. Candidates for the repair had ischemic cardiomyopathy and echocardiographic evidence of moderate or severe Carpentier type IIIb MR. Patients were followed with serial echocardiography.

RESULTS: Between January 2002 and November 2003, 25 adult patients underwent anterior leaflet augmentation for ischemic MR. Mean age was 64.8 ± 10.6 years, and mean left ventricular ejection fraction was 0.36 ± 0.14. Preoperative MR by transesophageal echocardiography was severe in 84% of patients and moderate in 16%. Annuloplasty band sizes were 27 mm to 31 mm (mean, 28.4 ± 1.1 mm). Concomitant coronary artery bypass grafting was performed in all patients. Transesophageal echocardiography immediately after repair revealed MR to be none or trace in 80% of patients and mild in 20%. No intraoperative conversion to valve replacement was performed. In follow-up, 2 patients have experienced moderate MR and are being treated medically, and no patients have mitral stenosis. At 2 years, actuarial freedom from moderate or greater MR is 81%.

CONCLUSIONS: For patients with ischemic MR, anterior leaflet augmentation is a simple and reproducible method of valve repair that addresses the pathophysiology of tethered leaflets. Early results in a small number of patients have been encouraging.

	Introduction

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The pathophysiology of ischemic mitral regurgitation (MR) is complex and poorly understood, and probably involves a multitude of anatomic and functional alterations in the subvalvular apparatus, often in conjunction with annular dilation. Traditional repair techniques that are based on reduction annuloplasty with rigid rings may alter leaflet and annular mechanics and increase left ventricular (LV) outflow gradients [1]. Additionally, studies detailing longitudinal valve-related outcomes for ring annuloplasty alone are difficult to find, but failure rates for this technique may be as high as 30% in patients with functional ischemic MR [2]. Newer methods of repair that are beginning to address the dysfunctional subvalvular apparatus involve complex judgment and repair methodology. For example, the pathophysiologic component of papillary muscle displacement with chordal tethering has been addressed by such techniques as secondary chord cutting [3], papillary muscle sling [4], papillary muscle relocation [5], and ventricular geometric restoration procedures [6]. The ability to widely apply these techniques and their longitudinal outcome is unknown.

In general, the leaflet tethering in ischemic MR is directed posterior to the central orifice of the mitral valve because both papillary muscles lie relatively posterior in the LV. On the basis of this anatomy, we sought a method of repair that allows the level of leaflet coaptation to fall more posteriorly and toward the level of the displaced papillary muscles. Because many patients with ischemic MR are severely ill with poor ventricular function, our attempts also focused on devising a technique that is easy to perform, avoids annuloplasty with a small ring, and preserves the subvalvular apparatus. The purpose of this study is to describe the technique and report the early results of anterior leaflet augmentation for ischemic MR.

	Material and methods

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This study was approved by the institutional review board of the Wake Forest University Baptist Medical Center.

Patient selection
Candidates for anterior leaflet augmentation were determined by preoperative and intraoperative echocardiography demonstrating restricted leaflet motion, without other signs of rheumatic valve disease, in combination with reduced ventricular ejection fraction and varying degrees of annular dilation. Our general policy is to intervene on symptomatic MR, 4+ MR, or grade 3+ MR or greater when other cardiac procedures are performed. Patients were not deemed ineligible on the basis of any level of ejection fraction, age, or comorbidity. During the study period, all mitral valve repairs for ischemic MR were performed using anterior leaflet augmentation and placement of an annuloplasty band, and this technique remains the standard approach at our institution.

Technique
The operation is performed through a median sternotomy, aortic and bicaval cannulation, moderate hypothermic cardiopulmonary bypass, and cold-blood retrograde cardioplegia. Distal coronary anastomoses are performed first, and other cardiac procedures are performed in sequence as indicated. We routinely expose the mitral valve through a superior septal incision. After inspection of the valve and confirmation of the pathophysiology, the mitral valve is brought closer into the operative field by placement of several 3-0 braided polyester sutures in the posterior annulus. These are later used for placement of a partial annuloplasty ring. An incision is made in the anterior leaflet, parallel to and approximately 5 mm from the hinge mechanism that extends across the anterior leaflet, stopping just short of each commissure (Fig 1). With the free edge of the leaflet now displaced centrally, the defect created in the anterior leaflet is in the shape of an ellipse. A piece of bovine pericardium (Shelhigh no-react pericardial patch, Shelhigh, Milburn, NJ) is then tailored to generously fill the defect. The approximate elliptical dimensions of the patch are typically 1 cm wide by 3 cm long. The patch is sewn into the defect using running 5-0 polypropylene suture (Fig 2). After sizing the intertrigonal distance, a flexible 27-mm to 31-mm posterior annuloplasty band (Duran ring, Medtronic, Minneapolis MN) is then placed from trigone to trigone using interrupted 3-0 braided polyester sutures (Fig 3).

View larger version (118K): [in this window] [in a new window]   Fig 1. The mitral valve as viewed from the surgeon's perspective with sutures in the posterior annulus. An incision is made in the anterior leaflet from commissure to commissure, with a resultant elliptical defect.

View larger version (115K): [in this window] [in a new window]   Fig 2. Anterior leaflet augmented with bovine pericardium.

View larger version (166K): [in this window] [in a new window]   Fig 3. Completed repair with partial, flexible annuloplasty ring.

	Results

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Between January 19, 2002, and November 25, 2003, 25 adult patients underwent anterior leaflet augmentation. Demographics are displayed in Table 1. Preoperatively, significant acute and chronic cardiac-related symptoms were common, including heart failure in 85%, acute myocardial infarction in 32%, and cardiogenic shock in 8%. Preoperative echocardiography revealed apical tethering of the leaflets in all patients and varying degrees of annular dilation. All patients had LV wall motion abnormalities secondary to ischemia or myocardial infarction. Preoperative and postoperative transesophageal echocardiography images are shown in Figures 4 and 5. Overall, the hinge point of the anterior leaflet was not altered by augmentation, and no prolapse of the anterior leaflet into the LV outflow tract was observed.

View larger version (73K): [in this window] [in a new window]   Fig 4. Preoperative transesophageal echocardiography long-axis views of the left ventricle. White arrow demonstrates tethering of the midportion of the anterior leaflet. Image on the right includes gray-scale Doppler demonstrating loss of central coaptation and severe mitral regurgitation.

View larger version (51K): [in this window] [in a new window]   Fig 5. Long-axis transesophageal echocardiography images of the left ventricle after anterior leaflet augmentation and placement of a 31-mm annuloplasty band. White arrow demonstrates pericardial patch. Image on the right with Doppler demonstrates central coaptation and competence of the valve.

Outpatient follow-up has been performed in 15 patients (60%) at a mean of 13 months postoperatively. Four patients are not yet 6 months postoperative, and 3 patients have been lost to follow-up. Intraoperative transesophageal echocardiography after repair revealed none or trace MR in 20 of 25 patients (80%) and mild MR in 5 of 25 (20%). No intraoperative conversion to valve replacement was performed. In follow-up, 2 patients have demonstrated moderate MR, including 1 patient receiving chronic prednisone treatment who has apparent partial dehiscence of the pericardial patch and 1 additional patient who has MR that has progressed from none immediately postoperatively, to mild at 6 months, to moderate at 12 months. The cause for this failure is not appreciable on transthoracic echocardiography, and transesophageal echocardiography has not been performed because she remains asymptomatic. No reoperation has been performed on either of these patients. Actuarial freedom from moderate or greater MR at 24 months is 81% (Fig 6). No patient has exhibited mitral stenosis or systolic anterior motion of the mitral valve. Thromboembolism has not occurred.

View larger version (13K): [in this window] [in a new window]   Fig 6. Mitral regurgitation (MR) after anterior leaflet augmentation. Actuarial follow-up reveals 2-year freedom from moderate or greater MR to be 81%.

	Comment

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In examining the physiologic results of the "standard" repair technique for ischemic MR, placement of an undersized annuloplasty ring, this repair reduces the anterior-posterior valve dimension by elevating the posterior annulus anteriorly toward the fibrous trigones. Theoretically, this will serve to increase leaflet tethering because the valve orifice becomes displaced away from the papillary muscles. Perhaps this mechanism is responsible for the necessity of the undersized annuloplasty ring and limits the durability of traditional repairs. Anterior leaflet augmentation allows the level of coaptation of the anterior and posterior mitral leaflets to fall more posteriorly and toward the direction of the displaced papillary muscles, thus relieving tension on the chords. Other potential advantages of anterior leaflet augmentation are that it does not require identification of the dynamically dysfunctional subvalvular apparatus in the static heart, does not result in the loss of leaflet support that may affect repair durability and alter LV function, and does not involve placing a rigid annuloplasty ring.

Materials other than bovine pericardium could certainly be used to augment the anterior leaflet, including homograft tissue and autologous pericardium. Our preference accounts for material strength, availability, and treatment of the product with an anticalcification agent. Although not attempted in this series, the repair could potentially be performed without an annuloplasty ring. However, the risks associated with placement of an appropriately sized annuloplasty band are low and are outweighed, in our opinion, by the risk of future LV and annular dilation.

In conclusion, anterior leaflet augmentation is a simple and reproducible method of valve repair for ischemic MR. The technique addresses the functional disturbances associated with regional wall motion abnormalities and loss of LV geometry. Although early results in a small number of patients have been encouraging, longer-term follow-up in a larger series of patients is needed.

	References

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1. Borghetti V., Campana M., Scotti C., et al. Biological versus prosthetic ring in mitral-valve repair: enhancement of mitral annulus dynamics and left-ventricular function with pericardial annuloplasty at long term. Eur J Cardiothorac Surg 2000;17:206-212.[Abstract/Free Full Text]
2. Tahta S.A., Oury J.H., Maxwell J.M., Hiro S.P., Duran C.M. Outcome after mitral valve repair for functional ischemic mitral regurgitation. J Heart Valve Dis 2002;11:11-18.[Medline]
3. Messas E., Guerrero J.L., Handschumacher M.D., et al. Chordal cutting: a new therapeutic approach for ischemic mitral regurgitation. Circulation 2001;104:1958-1963.[Abstract/Free Full Text]
4. Hvass U., Tapia M., Baron F., Pouzet B., Shafy A. Papillary muscle sling: a new functional approach to mitral repair in patients with ischemic left ventricular dysfunction and functional mitral regurgitation. Ann Thorac Surg 2003;75:809-811.[Abstract/Free Full Text]
5. Kron I.L., Green G.R., Cope J.T. Surgical relocation of the posterior papillary muscle in chronic ischemic mitral regurgitation. Ann Thorac Surg 2002;74:600-601.[Abstract/Free Full Text]
6. Menicanti L., Di Donato M., Frigiola A., et al. Ischemic mitral regurgitation: intraventricular papillary muscle imbrication without mitral ring during left ventricular restoration. J Thorac Cardiovasc Surg 2002;123:1041-1050.[Abstract/Free Full Text]
7. Timek T.A., Lai D.T., Tibayan F., et al. Septal-lateral annular cinching abolishes acute ischemic mitral regurgitation. J Thorac Cardiovasc Surg 2002;123:881-888.[Abstract/Free Full Text]

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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): Edward H. Kincaid Robert D. Riley Michael H. Hines John W. Hammon Neal D. Kon Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Kincaid, E. H. Articles by Kon, N. D. Search for Related Content PubMed PubMed Citation Articles by Kincaid, E. H. Articles by Kon, N. D. Related Collections Valve disease