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Ann Thorac Surg 2004;78:e36-e37
© 2004 The Society of Thoracic Surgeons

How to do it

Triangular plication of the anterior mitral leaflet: a new operative technique

Rainald Seitelberger, MDa*, Jan Bialy, MDa, Roman Gottardi, MDa, Wilfried Wisser, MDa, Ernst Wolner, MDa

a Department of Cardiothoracic Surgery, Allgemeines Krankenhaus Wien, Vienna, Austria

Accepted for publication December 29, 2003.

* Address reprint requests to Dr Seitelberger, Allgemeines Krankenhaus Wien, Abteilung Herz-Thoraxchirurgie, Waehringerguertel 18-20, A-1090 Vienna, Austria
e-mail: seitel{at}magnet.at


   Abstract
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 Abstract
Introduction
 Technique
 Comment
 References
 
This study describes the technique of triangular plication in patients with mitral valve incompetence that is due to segmental anterior leaflet prolapse. A nonabsorbable suture plicates the prolapsed leaflet area towards the ventricular aspect in a triangular fashion by decreasing the suture width towards the leaflet base. Because no leaflet tissue is resected, this technique allows for the intraoperative correction of an imperfect plication. Triangular plication was successful in all except one patient. In this patient, a failed repair was corrected with mitral valve replacement. Freedom from mitral valve incompetence of more than grade 0–I was 100% at 12 months and 86% at 36 months postoperatively.


   Introduction
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 Abstract
 Introduction
Technique
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Whereas repair of segmental prolapse of the redundant posterior mitral valve leaflet by plication or excision is a relatively easy and durable technique [1], correction of segmental anterior leaflet prolapse (SALP) is technically more demanding and less reproducible. In this report we analyze our early experience with the reconstructive technique of triangular plication for patients with SALP.


   Technique
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Between August 1999 and August 2002, triangular plication was performed in 17 patients with grade III or IV mitral valve incompetence (MVI) that was due to degenerative (myxomatous or nonmyxomatous, n = 16) or rheumatic (n = 1) disease. Two patients had an isolated SALP, all other patients presented with additional valve pathology. Additional procedures (n = 8) included coronary artery bypass grafting, the maze procedure, and tricuspid valve reconstruction. Follow-up (mean follow-up, 2.31 years; range, 12 to 48 months) included intraoperative transesophageal echocardiography (TEE) and repeated postoperative transthoracic echocardiography.

All additional valve lesions were repaired before the triangular plication of the SALP was performed. Reconstructive techniques for those lesions included quadrangular resection, sliding plasty, annulus decalcification, and the transfer or cutting of secondary chordae.

Initially, the size of the SALP was evaluated and chordae from the prolapsed area and the adjacent secondary chordae were resected. For triangular plication, we initially used a single, nonabsorbable 6-0 running suture (n = 10) but eventually changed to multiple single sutures (n = 7). In both cases, the suture plicates and inverts the prolapsed area towards the ventricular aspect of the leaflet in a triangular fashion by decreasing the suture width with the base of the triangle at the edge of the leaflet and its tip positioned towards the leaflet base (Fig 1A and B). The left ventricle was filled with saline, and if this demonstrated residual incompetence because of an oversized or undersized plication, the sutures were cut and repositioned by adapting their width. The maximal width of the base of the triangle did not exceed 1.5 cm. Every repair was completed with the implantation of a prosthetic mitral valve ring (Physio Annuloplasty Ring, Edwards Lifesciences Corp, Irvine, CA).



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  		Fig 1. (A) Schematic drawing of segmental anterior leaflet prolapse (SALP) with suture line for triangular plication. Result (B) after triangular plication of SALP with inversion of the plicated area towards the ventricular aspect of the anterior leaflet (inset).

 
No early or late deaths occurred. In three patients, intraoperative evaluation by left ventricular filling revealed residual incompetence due to oversized (n = 2) or undersized (n = 1) triangular plication sutures. Repositioning of the plication sutures solved this problem and yielded a perfectly competent valve. In one patient with rheumatic disease, TEE after termination of cardiopulmonary bypass demonstrated a residual MVI (grade II), and a prosthetic mitral valve was implanted. The intraoperative reevaluation suggested that residual restriction of the posterior leaflet was the primary cause of repair failure.

Mitral valve repair was successful in the other 16 patients (94%), in whom freedom from residual MVI (none or trivial, grade 0 or 0–I) was 100%, 100%, 90%, and 86%, at 12 (n = 16), 18 (n = 13), 24 (n = 10), and 36 (n = 7) months postoperatively. A moderate MVI (grade I–II) was diagnosed in 1 patient at 24 months. In none of the patients was a systolic anterior motion phenomenon or any evidence of mitral stenosis observed early or late postoperatively.


   Comment
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 Abstract
 Introduction
 Technique
 Comment
References
 
Whereas successful repair of posterior leaflet prolapse can be achieved in almost all cases, repair of anterior leaflet prolapse remains a surgical challenge. Various techniques have been successfully introduced, but most procedures are either technically challenging and less reproduceable, or lack sufficient follow-up data to evaluate their efficacy.

Techniques that primarily target anterior leaflet chordae, such as chordal shortening and the transposition or insertion of new chordae, have gained widespread use. Most studies have indicated that the insertion of artificial chordae is associated with more increased freedom from reoperation at long term than is chordal shortening or chordal transposition [2, 3]. In contrast, Galloway and colleagues [4] recently concluded that the late durability after anterior leaflet repair was not influenced by the technique used.

Other techniques, such as chordal plication and free edge remodeling [5] or posterior papillary muscle repositioning [6], are not as common, probably due to their technical complexity, and cannot be applied in cases of anterior leaflet chordal rupture.

The concept of triangular plication of SALP is based on the mixed historical experience with mitral leaflet plication techniques [7] and the excellent experience with triangular resection of SALP [4, 8]. However, the biggest disadvantage of triangular resection, especially in inexperienced hands, remains the irrevocable act of excising a piece of tissue without the possibility to estimate its final impact on the outcome of the repair. In contrast to triangular excision, triangular plication offers the possibility for immediate intraoperative correction in case of a failed SALP repair by readapting the width of the plicated area. The positive impact of this intraoperative "window for correction" was evident in our series, where the repositioning of plication sutures was successfully performed in 3 patients.

The results of our initial series demonstrate that this technique is easy to perform and is reproducible in patients with degenerative valve disease. Mitral valve repair for correction of a SALP was successful in 16 out of 17 patients and remained effective during the mean follow-up period of 2.31 years, independent of the suture technique that was used.

Restrictions of triangular plication include anterior leaflet calcification, a large prolapse extending over more than one third of the leaflet area, or a segmental prolapse that includes the commissural area. Initially, we were also concerned that the leaflet tissue plicated towards the ventricular aspect of the anterior leaflet might cause flow disturbances in the left ventricular outflow tract similar to the well-described systolic anterior motion phenomenon. However, clinical and echocardiographic follow-up data did not demonstrate any indication that the plicated tissue had an unfavorable impact on the flow characteristics of the left ventricular outflow tract.

In conclusion, triangular plication of SALP is a technically easy and reproducible technique in patients with MVI that is due to SALP and, specifically, offers the option of an immediate intraoperative correction of suboptimal repairs. Consequently, it appears to be a valuable addition to other reconstructive techniques. Longer follow-up in more patients will eventually determine its role in the field of reconstructive mitral valve surgery.


   References
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 Abstract
 Introduction
 Technique
 Comment
 References
 

  1. Carpentier A. Cardiac valve surgery—the "French correction". J Thorac Cardiovasc Surg 1983;86:323-337.[Medline]
  2. Phillips M.R., Daly R.C., Schaff H.V., Dearani J.A., Mullany C.J., Orszulak T.A. Repair of anterior leaflet mitral valve prolapse. Chordal replacement versus chordal shortening. Ann Thorac Surg 2000;69:25-29.[Abstract/Free Full Text]
  3. David T.E., Omran A., Armstrong S., Sun Z., Ivanov J. Long-term results of mitral valve repair for myxomatous disease, with and without chordal replacement with expanded polytetrafluoroethylene sutures. J Thorac Cardiovasc Surg 1998;115:1279-1286.[Abstract/Free Full Text]
  4. Galloway A.C., Grossi E.A., Bizekis C.S., et al. Evolving techniques for mitral valve reconstruction. Ann Surg 2002;236:288-294.[Medline]
  5. Fundaro P., Moneta A., Villa E., et al. Chordal plication, and free edge remodeling for mitral anterior leaflet prolapse repair. 8-year follow-up. Ann Thorac Surg 2001;72:1515-1519.[Abstract/Free Full Text]
  6. Dreyfus G.D., Bahrami T., Alayle N., Mihealainu S., Dubois C., De Lentdecker P. Repair of anterior leaflet prolapse by papillary muscle repositioning: a new surgical option. Ann Thorac Surg 2001;71:1464-1470.[Abstract/Free Full Text]
  7. Ellis F.H., Jr, Frye R.L., McGoon D.C. Results of reconstructive operations for mitral insufficiency due to ruptured chordae tendineae. Surgery 1966;59(1):165-172.[Medline]
  8. 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]



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This Article
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Wilfried Wisser
Ernst Wolner
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