Ann Thorac Surg 2004;78:1484-1485
© 2004 The Society of Thoracic Surgeons
How to do it
A Method to Avoid Annular Downsizing During Knot Tying
Francesco Maisano, MDa,*,
Andrea Blasio, MDa,
Alessandro Caldarola, MDa,
Carlo Savini, MDa,
Ottavio Alfieri, MDa
a Department of Cardiac Surgery, San Raffaele Hospital, Milan, Italy
Accepted for publication August 28, 2003.
* Address reprint requests to Dr Maisano, Cardiochirurgia, Ospedale San Raffaele, Via Olgettina 60, 20132 Milan, Italy
francesco.maisano{at}hsr.it
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Abstract
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Pericardial annuloplasty has been used as an alternative to prosthetic annuloplasty. One drawback of pericardial annuloplasty is the risk of cinching of tissues during knot tying, possibly leading to uncontrolled downsizing and to complications such as mitral stenosis and systolic anterior motion of the anterior leaflet. A simple modification of the sequence of knot tying is described to avoid this complication.
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Introduction
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Annuloplasty provides higher freedom from reoperation when applied in valve reconstruction for mitral valve regurgitation [1]. Several techniques for mitral annuloplasty, mostly with a prosthetic support, have been described. Less commonly, autologous pericardium has been used as a biocompatible, low-cost, and fully flexible support for posterior ring annuloplasty [2].
An important drawback of posterior annuloplasty with the autologous pericardium is the risk of cinching of the strip of tissue when the sutures are tied. This may lead to excessive annular constriction and the occurrence of a stenotic mitral valve orifice or an increased risk of postoperative systolic anterior motion of the anterior leaflet. Suboptimal sizing and implantation may also affect long-term durability [3]. To avoid these complications, my colleagues and I used an alternative method to tie the sutures on the pericardium strip that reduces the risk of inadvertent annular downsizing.
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Technique
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A 1-cm-wide and approximately 10-cm-long strip of tissue is dissected free from areolar tissue and removed from the anterior pericardium. The strip is placed on a wet sponge, avoiding wrinkles. Approximately 50 mL of buffered 0.65% glutaraldehyde solution is poured over the strip and the sponge. The sponge is then placed into laparotomic gauze to compress the pericardial strip. The laparotomic gauze is left flat for 15 minutes; thereafter, the strip is taken out of the sponge and rinsed in cold water to eliminate the excess glutaraldehyde. The strip is then left in cold water until it is used for the annuloplasty.
After completion of the valve reconstruction procedure, 8 to 12 horizontal interrupted sutures (2-0 TI · CRON; Tyco Healthcare, Mansfield, MA) are passed through the posterior annulus in standard fashion. The sutures are placed starting from the posterior trigone and ending at the anterior trigone. The inclusion of the trigones in the suture is mandatory to stabilize the annular reduction and to avoid late redilation. Depending on the surgeon's preferences, the annulus can be sized either before or after annular sutures are placed. The length of the strip is then determined with the aid of a prosthetic ring sizer. We use a Seguin Ring (St Jude Medical; St Paul, MN) sizer to measure both the intertrigonal distance and the anterior leaflet surface area to select the size. The pericardial strip is tailored to correspond to the circumference of the posterior portion of the ring sizer, and 2 cm is added to account for the distance from the commissures to the trigones. The sutures are then passed through the strip, taking care to place the serosal surface on top. Suture tying is then performed in an original manner (Fig 1). Knot tying starts at the posterior trigone. Both ends of the first suture are tied together. It can be useful to retain one of the needles of the suture, because after the knot is tied, one end can be buried down, passing the suture again through the pericardial strip. This end of the suture is then tied with the closest end of the next suture, and so on, as shown in the figures. During this phase the assistant should firmly hold the remaining untied sutures to avoid sliding of the untied free end of the following sutures. Therefore, sutures are tied in sequence, creating a chain of annular sutures supported by the pericardial strip and connecting the trigones. The final result is a completely flat pericardial strip, which retains the size as it was selected when the pericardium was cut on the basis of the measurements (Fig 2).
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Fig 1. Sequence of knot tying. (Left) The effect of conventional knot tying, which results in plication of the annular and pericardial tissue. (Right) The effect of the modified technique.
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Fig 2. After knot tying with the modified sequence, the pericardial strip lies flat above the posterior annulus.
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From January 2000 through December 2002 this technique was applied in 23 selected patients, with a mean age of 61 ± 13 years. There were 12 men and 11 women, all of whom presented with severe mitral valve regurgitation. The cause was degenerative in 12 patients, rheumatic in 3, endocarditic in 5, functional in 2, and congenital (incomplete atrioventricular septal defect) in 1. Most patients (75%) were in New York Heart Association (NYHA) functional class III.
The decision to use a pericardial strip instead of a prosthesis was based on different reasons. In 5 patients the pericardium was used because of acute or subacute endocarditis. In 5 patients it was used in the presence of focal annular calcifications to reduce the risk of dehiscence. In the remaining 13 patients the pericardial strip was preferred because of specific anatomic situations. In 1 case it was used to support valve repair after cleft repair associated with an incomplete atrioventricular septal defect (to adjust for the specific annular anatomy). In 2 cases of functional mitral regurgitation the posterior pericardial strip was selected because of the difficulty of exposing the anterior annulus. In the remaining 9 patients, who mainly had degenerative disease, the pericardial posterior annuloplasty was used to avoid systolic anterior motion, particularly in the presence of anterior leaflet billowing.
Mitral valve repair techniques included quadrangular resection of the posterior leaflet in 13 cases, edge-to-edge repair in 8 cases (double orifice repair in 3 and paracommissural repair in 5), and patch repair of perforations with glutaraldehyde treated pericardium in 2 cases.
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Results
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No patient died during the hospital stay, which was uneventful in most cases. At a mean follow-up of 21.4 ± 7.3 months, there were no deaths; 1 patient had recurrent endocarditis and underwent mitral valve replacement. At the latest follow-up, 18 patients (81.8%) were in NYHA class I, and 6 were in NYHA class II. The latest available echo-Doppler examination (excluding the reoperated patient) results showed no mitral regurgitation in 11 cases, trivial regurgitation (1+/4+) in 8 cases, and moderate regurgitation (2+/4+) in 3 cases. No patient had annular redilation during the follow-up period. No patient had mitral stenosis at the Doppler estimation of valve area.
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Comment
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Autologous pericardium has been used as a biologic fully flexible support for posterior C annuloplasty, with results comparable to those with prosthetic ring annuloplasty. The potential benefits of pericardium over prosthesis are higher biocompatibility, less risk of infection (it is the material of choice for active infective endocarditis), and better cost-effectiveness.
One of the major drawbacks is the risk of undesired undersizing due to cinching of the strip during tying the sutures because of the flexibility of the pericardium. To overcome this limitation, prosthetic flexible annuloplasty devices have been designed with specific holders that allow correct sizing and supported tying [4].
This method of suture tying allows firm and secure tying of the sutures with autologous pericardium without the risk of inadvertent annular downsizing. This minimal modification of the standard technique may allow safe adoption of pericardial annuloplasty in selected patients [5], such as those with acute infective endocarditis, those with focal calcified annulus, or those with absolute contraindications for oral anticoagulants.
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References
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- Gillinov AM, Cosgrove DM, Blackstone EH, et al. Durability of mitral valve repair for degenerative disease. J Thorac Cardiovasc Surg. 1998;116:734–743[Abstract/Free Full Text]
- Scrofani R, Moriggia S, Salati M, Fundaro 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]
- Bevilacqua S, Cerillo AG, Gianetti J, et al. Mitral valve repair for degenerative disease: is pericardial posterior annuloplasty a durable option? Eur J Cardiothorac Surg. 2003;23:552–559[Abstract/Free Full Text]
- Gillinov AM, Cosgrove DM III, Shiota T, et al. Cosgrove-Edwards Annuloplasty System: midterm results. Ann Thorac Surg. 2000;69:717–721[Abstract/Free Full Text]
- Ng CK, Nesser J, Punzengruber C, et al. Valvuloplasty with glutaraldehyde-treated autologous pericardium in patients with complex mitral valve pathology. Ann Thorac Surg. 2001;71:78–85[Abstract/Free Full Text]
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Abstract
Introduction
