Ann Thorac Surg 2005;79:720-722
© 2005 The Society of Thoracic Surgeons
How to do it
A Technique for Annular Plication to Facilitate Sliding Plasty After Extensive Mitral Valve Posterior Leaflet Resection
Thierry Mesana, MD, PhDa,*,
Moheb Ibrahim, FRCSCa,
Mark Hynes, FRCPCb
a Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
b Division of Cardiac Anesthesia, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
Accepted for publication November 21, 2003.
* Address reprint requests to Dr Mesana, Division of Cardiac Surgery, University of Ottawa Heart Institute, 40 Ruskin St, Ottawa, Ontario, Canada K1Y 4W7
tmesana{at}ottawaheart.ca
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Abstract
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The sliding leaflet technique has been used in mitral valve repair in conjunction with posterior leaflet quadrangular resection to avoid left ventricular outflow tract obstruction secondary to systolic anterior motion of the anterior leaflet of the mitral valve. On occasion, despite the use of the sliding leaflet technique, reattachment of the edges of the posterior leaflet after extensive resection can be challenging because of excessive tension. My colleagues and I present our technique to ensure reattachment of the posterior leaflet without tension after extensive resection.
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Introduction
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Mitral valve repair is the procedure of choice for mitral regurgitation due to degenerative disease [1]. Ruptured or elongated chordae to the posterior leaflet are the most common culprits. Mitral valve repair for degenerative mitral valve disease with quadrangular resection of the posterior leaflet and annuloplasty can be complicated by left ventricular outflow tract obstruction due to systolic anterior motion (SAM) of the anterior mitral leaflet [2–4]. Carpentier [5] developed a sliding leaflet technique to prevent this complication. However, sometimes prolapse affects not only the middle scallop (P2) of the posterior leaflet, but also both the anterolateral (P1) and posteromedial (P3) scallops. This requires extensive resection of the posterior leaflet, thus rendering the task of reattaching the remnants of the posterior leaflet a challenging one, particularly when the detachment of P1 and P3 has been extended to both commissures. This has not yet been well described in the literature. Therefore, my colleagues and I present our technique of annular plication to avoid excessive tension during reattachment of the posterior leaflet after extensive resection.
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Technique
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Mitral valve operations are routinely performed by using bicaval venous cannulation, mild systemic hypothermia, and antegrade cold crystalloid cardioplegia. After the left atrium is opened, valve exposure is facilitated by passing several double-armed 2-0 Ethibond (Ethicon Inc, Somerville, NJ) sutures through the posterior section of the annulus, from one commissure to the other (Fig 1B). These sutures are 5-mm-wide U-stitches, and, most importantly in our technique, are used later to achieve homogeneous plication of the posterior section of the annulus. The mitral valve is carefully assessed, and the prolapsed segments are identified. Resection is performed of P2 and of the prolapsed segments of P1 and P3. In case of extensive posterior leaflet resection, the sliding plasty involves an extensive section of the posterior aspect of the annulus, and the remaining portions of the P1 and P3 components are detached from the annulus up to the commissures (Fig 1B). The length of detachment from the annulus should be kept equal on each side, thereby achieving a balanced sliding. To facilitate approximation of the edges of the posterior leaflet without undue tension, it is important to tie down the annular plicating Ethibond sutures before attempting to reattach the remnants of the posterior leaflet. This will progressively plicate and, therefore, narrow the posterior annulus. This is the most crucial step in our technique: it allows a tension-free reattachment of the remnants of the posterior leaflet. This is clearly illustrated by comparing Figure 1C with Figure 1A. The edges of the posterior leaflet (points b and c) can easily overlap, making the task of reattaching them an easy one. Subsequently, another set of 2-0 Ethibond sutures (usually half the number of plicating sutures because the posterior annulus has already been narrowed) are placed around the posterior annulus for ring or band implantation (Fig 1D). A continuous 5-0 Prolene (Ethicon) suture is then used to reattach the posterior leaflet remnants to the posterior annulus, and interrupted 5-0 Prolene sutures are used to join the 2 edges of the posterior leaflet (Fig 1D). It is important to note that the insertion of the second set of Ethibond annular sutures should precede reattachment of the posterior leaflet to the annulus so that they can be inserted under direct vision. The mitral annulus is sized, and an annuloplasty ring or band of the surgeon's choice is inserted by using the usual technique.
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Fig 1. Annular plication to facilitate the sliding leaflet technique after extensive resection of the mitral valve posterior leaflet. (A) Mitral valve before posterior leaflet resection. Twelve plicating 2-0 Ethibond sutures are inserted into the posterior annulus, markedly improving exposure of the mitral valve. (B) Resection of P2 and parts of P1 and P3 and detachment of P1 and P3 up to the commissures. (C) The 12 Ethibond sutures are tied down, thereby gradually narrowing the posterior part of the mitral annulus. Note that edges b and c are brought close enough that they overlap. (D) A second set of 2-0 Ethibond sutures (half the number of plicating sutures) are then inserted in the posterior annulus. The remnants of the posterior leaflet are easily reattached to the posterior annulus and to each other. (a = anterolateral commissure; b and c = margins of posterior leaflet resection; d = posteromedial commissure.)
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Comment
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Quadrangular resection of the posterior leaflet of the mitral valve is an established technique for mitral regurgitation secondary to degenerative mitral valve disease [1]. However, left ventricular outflow tract obstruction due to SAM occurs in approximately 4.5% to 5% of cases [2–4]. SAM is caused by anterior displacement of the line of leaflet coaptation [6] that requires the presence of redundant posterior leaflet tissue [7]. The traditional plication of the annulus in a single location, as described in the original quadrangular resection, may in itself contribute to SAM and must be avoided [8]. This prompted the development of a sliding leaflet advancement technique by Carpentier [5]. However, the surgeon may be faced with prolapse of P2, as well as parts of P1 and P3, of the posterior mitral leaflet, which requires resection not only of P2 but also of parts of P1 and P3. In this situation, Carpentier's original sliding plasty may not be sufficient to achieve reconstruction of the posterior leaflet without tension. With this scenario, our technique of annular plication becomes crucial to bring the edges of the remaining parts of the posterior leaflet together without excessive tension and to avoid plication at a single location, which can predispose to SAM and may compromise the circumflex coronary artery flow. We found it very useful to insert and tie down 10 to 12 double-armed 2-0 Ethibond posterior annular sutures before attempting to reattach the remnants of the posterior leaflet to the annulus and to each other. By doing so, the repair will be completely tension free, and the narrowing of the posterior section of the annulus will be gradually and homogeneously achieved. Figure 1C shows how easily the edges b and c overlap despite extensive resection. Because the posterior part of the annulus is already narrowed after the plicating sutures are tied down, the number of the sutures used for ring or band implantation is only half the number of plicating sutures. This second set of sutures should be inserted under direct vision before reattachment of the posterior leaflet. The repair is, thereafter, completed by passing those sutures into an annuloplasty ring or a posterior band. Should the surgeon prefer to insert a ring, Ethibond sutures are inserted in the anterior part of the annulus as well.
Out of 69 consecutive mitral valve repairs for degenerative or myxomatous disease performed from October 2001 through April 2003, 46 patients demonstrated posterior leaflet prolapse with or without anterior leaflet prolapse. Of these 46 patients, 32 were found to have P1 or P3 prolapse (or both) in addition to P2 prolapse, thus requiring more extensive resection of the posterior leaflet. Among these 32 patients, 11 patients had anterior leaflet prolapse that also required repair. For the 32 patients who required more extensive resection of the posterior leaflet, we applied our modified technique of extended annular plication. Postrepair intraoperative transesophageal echocardiography did not reveal SAM or significant residual mitral regurgitation. Also, we applied this technique for 2 patients with annular calcification where the annulus was plicated in a similar fashion after complete decalcification.
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References
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- Carpentier A. Cardiac valve surgery-the "French correction". J Thorac Cardiovasc Surg. 1983;86:323–337[Medline]
- Kreindel MS, Schiavone WA, Lever HM, Cosgrove DM. Systolic anterior motion of the mitral valve after Carpentier ring annuloplasty for mitral valve prolapse. Am J Cardiol. 1986;57:408–412[Medline]
- Kronzon I, Cohen ML, Winer HE, Colvin SB. Left ventricular outflow tract obstruction: a complication of mitral valvuloplasty. J Am Coll Cardiol. 1984;4:825–828[Abstract]
- Stewart WJ, Currie PJ, Lytle BW, et al. Intraoperative Doppler color flow mapping for decision making in valve repair for mitral regurgitation: technique and results in 100 patients. Circulation. 1990;81:556–566[Abstract/Free Full Text]
- Carpentier A. The sliding leaflet technique. Club Mitrale Newslett. 1988;1:2–3
- Lee KS, Stewart WJ, Lever HM, et al. Mechanism of outflow obstruction following failed valve repair: anterior displacement of leaflet coaptation. Circulation. 1993;88(Suppl 2):II24–29
- Mihaileanu S, Marino JP, Chauvaud S, et al. Left ventricular outflow obstruction after mitral repair (Carpentier's technique). Proposed mechanism of disease. Circulation. 1988;78(Suppl 1):I78–84
- David TE. Invited letter concerning: correction of prolapse of the anterior leaflet of the mitral valve. J Thorac Cardiovasc Surg. 1992;104:1489
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Abstract
Introduction
