Ann Thorac Surg 2005;79:1496-1499
© 2005 The Society of Thoracic Surgeons
Original articles: Cardiovascular
Minimally Invasive Mitral Valve Repair in the Context of Barlow's Disease
Elisabetta Lapenna, MDa,*,
Lucia Torracca, MDa,
Michele De Bonis, MDa,
Giovanni La Canna, MDa,
Giuseppe Crescenzi, MDb,
Ottavio Alfieri, MDa
a Department of Cardiac Surgery, San Raffaele University Hospital, Milan, Italy
b Department of Anesthesiology, San Raffaele University Hospital, Milan, Italy
Accepted for publication October 20, 2004.
* Address reprint requests to Dr Lapenna, Divisione di Cardiochirurgia, IRCCS Ospedale Universitario San Raffaele, Via Olgettina, 60, 20132 Milan, Italy; (E-mail: lapenna.elisabetta{at}hsr.it).
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Abstract
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BACKGROUND: The aim of this study is to report our overall experience with minimally invasive mitral valve repair for correction of severe mitral regurgitation in the setting of Barlow's disease.
METHODS: Between 1999 and 2003, 48 patients with bileaflet prolapse in the context of Barlow's disease underwent minimally invasive mitral valve repair using the "edge-to-edge" technique. Mean age was 37.9 ± 9.1 and 58% were female. Most of the patients were in New York Heart Association (NYHA) class I or II and all of them had normal left ventricular ejection fraction.
RESULTS: There were no conversions to sternotomy. Mean cardiopulmonary bypass and aortic cross-clamp times were 77 ± 16 minutes and 56 ± 8 minutes. No in-hospital deaths and no major postoperative complications occurred. At a mean follow-up of 22.7 ± 10.6 months, survival rate and freedom from reoperation were 100%. All patients were in NYHA class I and in sinus rhythm. No residual mitral regurgitation was detected at echocardiography in 33 (68.7%) patients and mild insufficiency was found in 15 (31.2%). The degree of satisfaction in terms of cosmesis and postoperative pain was very high and 73% of the patients were back to work and to normal activity in 4 weeks.
CONCLUSIONS: Mitral insufficiency due to Barlow's disease can be effectively corrected through a minimally invasive approach by using the "edge-to-edge" technique. In our opinion, the excellent midterm results and the high degree of patients satisfaction certainly justify the adoption of this strategy in a selected group of young and active people.
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Introduction
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Repair of mitral regurgitation (MR) caused by prolapse of both leaflets in the presence of severe myxomatous degeneration (Barlow's disease) requires complex reconstructive techniques and is usually considered too challenging to be performed through a minimally invasive approach [1]. That is the reason why, so far, only a few cases of minimally invasive mitral valve reconstruction have been reported in this setting. A policy of early surgery indication is, today, rather common in the presence of degenerative severe mitral insufficiency [2]. However, in the presence of few or no symptoms, most of the patients are very reluctant to undergo a major operation through a sternotomy approach and, particularly the young women, are often very attracted by the possibility of a minimally invasive procedure. The main advantages of this approach are represented by better cosmetic results, minimized surgical trauma, reduced postoperative pain, and faster recovery [3]. The edge-to-edge technique is very effective for the treatment of mitral regurgitation due to Barlow's disease and, because of its technical simplicity, it can be easily applied through a minimally invasive approach [4, 5]. The purpose of this study is to report our overall experience with minimally invasive mitral valve repair for correction of mitral regurgitation due to bileaflet prolapse in this context.
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Material and Methods
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Patients
Between October 1999 and September 2003, 48 patients, affected by prolapse of both leaflets in the context of Barlow's disease, underwent video-directed minimally invasive mitral valve repair at San Raffaele University Hospital. Mean age was 37.9 ± 9.1 years (range, 15 to 60) and 28 patients were female (58%). Patients with previous right thoracotomy, excavated pectus, significant pulmonary hypertension, and moderate aortic regurgitation were excluded from this approach. All patients were operated on electively, had normal left ventricular ejection fraction, and were in sinus rhythm. At admission, most of the patients (75%) were in New York Heart Association (NYHA) functional class I or II and all of them had a grade 3+ or 4+ mitral regurgitation. The mechanism of mitral insufficiency was a bileaflet prolapse in all the patients. Mean left ventricular dimensions were the following: end-diastolic diameter 52 ± 4 mm, end-systolic diameter 35 ± 3.7 mm, end-diastolic volume 104.3 ± 17.37 mL, and end-systolic volume 42 ± 6 mL.
Surgical Technique
Patients were intubated with a double-lumen endotracheal tube and a transesophageal echocardiographic probe was inserted to supervise the whole surgical procedure, from the insertion of the venous cannulas to the final assessment of mitral reconstruction. A 14 F cannula was placed percutaneously through the right jugular vein into the superior vena cava. A 6 to 8 cm minithoracotomy was performed through the fourth intercostal space (Fig 1) and a soft tissue retractor (Heartport, Inc, Redwood City, CA) was used for spreading the ribs. One port was created laterally to the incision to introduce both a 5 mm video scope and a carbon dioxide line to flush the operative field. Pericardial stay sutures were passed through and fixed out of the chest. Femoral vessels cannulation was performed and cardiopulmonary bypass (CPB) was established between the femoral artery and femoral and jugular veins, at 28 to 30°C. Aortic cross-clamp and cardioplegia delivery were obtained by two different techniques. In 44 patients the aortic clamping was achieved using the Chitwood transthoracic clamp (Scanlan International, Inc, Minneapolis, MN) inserted through the second or third intercostal space, and intermittent antegrade cardioplegia was administered through an aortic root catheter. In the remaining four patients we used an endoaortic balloon (Heartport, Inc, Redwood City, CA), placed under echo guidance in the ascending aorta through the femoral cannula. After balloon inflation, the cardioplegia was delivered through the tip of the catheter. The mitral valve was exposed in all cases through a left atriotomy using a transthoracic atrial retractor positioned in the fourth intercostal space just lateral to the right sternal border. The valve was analyzed and repaired by direct vision through the minithoracotomy incision. Whenever the view was suboptimal, the inserted camera was used to improve valve assessment and reconstruction (Fig 2). A double-orifice repair was performed in all patients. The technical details of this repair have been described before [4, 6]. Briefly, the middle portion of each leaflet was identified and the corresponding free edges approximated with a running 4–0 polypropylene suture producing a double orifice mitral valve. A prosthetic ring annuloplasty was associated in all cases to reshape and reduce the annular orifice (Fig 3). Long-shafted Heartport instruments, passed through the minithoracotomy, allowed suture placement, annuloplasty ring implantation, and knot tying.
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Fig 2. Intraoperative video scope view of a typical Barlow's mitral valve (A) with enormous hoodlike bulging due to excess tissue of all segments of the leaflets (B).
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Fig 3. Intraoperative view of the mitral valve repaired using the edge-to-edge technique and a prosthetic ring annuloplasty: (A) The placement of the first stitch of the edge-to-edge suture; (B) the final result of the reconstruction.
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Transesophageal echo-Doppler assessment of the valve was routinely done after weaning from cardiopulmonary bypass and a transthoracic echocardiography was performed right before hospital discharge. Operative data are shown in Table 1.
Follow-Up
Follow-up ranged from 3 to 48 months (mean, 22.7 ± 10.6) and was 100% complete. Thirty-nine patients (81.2%) were reviewed in our outpatient clinic where a transthoracic echocardiogram was performed together with a clinical assessment. The remaining 9 patients (18.8%), living in remote geographical areas, did not come back to our unit late after the operation. In those cases the clinical and echocardiographic assessment was done by the referring cardiologist, and the related data were collected through telephone contact with both the patient and his physician. All 48 patients were asked about their functional class, and in addition, about the grade of pain they suffered during the postoperative period, how fast after surgery they had returned to an active life, and whether they were satisfied by the aesthetic result. The last follow-up data collection was performed between November and December 2003.
Statistical Analysis
All data were prospectively collected in a dedicated database. Statistical data are expressed as percent or mean ± standard deviation. The statistical package used was SPSS version 10 (SPSS Inc, Chicago, IL).
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Results
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All the mitral valves were repaired and there were no conversions to sternotomy. Mean CPB and aortic cross-clamp times were 77 ± 16 minutes and 56 ± 8 minutes, respectively. There were no in-hospital deaths. Mean mechanical ventilation and intensive care unit stay time were 6 ± 3.2 and 13 ± 5.4 hours, respectively. There were no cases of perioperative myocardial infarction, neurologic complication, acute renal failure, reexploration for bleeding, postoperative peripheral ischemia, or thoracic or groin wound infection. Atrial fibrillation occurred in 10 patients (21%) and was medically treated. One patient needed blood transfusion and another one required a postoperative drainage of right pleural effusion. Leg lymphoedema was observed in one case on postoperative day 5. One patient, with associated tricuspid annuloplasty, required a pacemaker implantation. Mean hospital stay was 4 ± 1.1 day and predischarge echocardiogram documented no residual mitral regurgitation in 35 (72.9%) patients and mild insufficiency in 13 (27.1%).
At a mean follow-up of 22.7 ± 10.6 months, survival rate and freedom from reoperation were 100% and all patients were in NYHA class I and sinus rhythm. Follow-up transthoracic echocardiography demonstrated no residual mitral regurgitation in 33 (68.7%) patients and mild mitral insufficiency in 15 (31.2%). The mean planimetric valve area was 3.1 ± 0.7 cm2. All patients had a high degree of satisfaction in terms of comfort and cosmesis experiencing minimal procedure-related pain. Thirty-five patients (73%) were back to work and to normal activity in 4 weeks after surgery and the remaining 13 patients in 6 weeks.
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Comment
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In Barlow's disease, all the components of the mitral valve apparatus are involved by a myxomatous degeneration which eventually leads to generalized bileaflet prolapse, important annular dilatation, and severe mitral insufficiency. The free edges of these myxomatous valves are often irregular, with an increased number of clefts and multiple regurgitant jets at Doppler echocardiography [1]. In such a context, a conventional anatomic reconstructive approach requires a long operation, which, although successfully performed by many experienced surgeons, is technically demanding, not easily reproducible, and sometimes associated to suboptimal results. Hence, performing such a complex mitral repair through a minimally invasive approach has been questioned and deemed to be too difficult [7], requiring a prolonged aortic cross-clamp time, which can affect immediate and long-term results. To the best of our knowledge, very few cases of Barlow's mitral valve repair have been described even in the largest series of minimally invasive mitral valve surgery [3, 8–11]. Indeed, only Casselman and colleagues [3] reported 9 cases of Barlow's disease out of 226 patients undergoing mitral valve reconstruction through a minithoracotomy. However, a small incision, 6 to 8 cm just in the inframammary groove, is cosmetically appealing particularly to young women who are extremely attracted by having an aesthetic scar and a faster return to an active life. Today, along with the spreading (in such a context) of an "early" surgery policy, a minimally invasive procedure is more and more often requested by the patients themselves, who are understandably reluctant to undergo a major operation through a sternotomy approach with no or few symptoms [2]. On the basis of our experience, complex prolapse in Barlow's disease can be effectively corrected through a right minithoracotomy with the edge-to-edge technique. The basic concept of this repair is that mitral regurgitation can be addressed simply by suturing together the free edges of the diseased mitral leaflets just at the site where the regurgitant jet occurs. The operative steps and the 5-year results of this technique in the setting of Barlow's disease through a conventional midline sternotomy have already been reported [4, 5]. With increasing experience, we have started to use the edge-to-edge in Barlow's disease also through a minimally invasive access with cross-clamp times comparable to those recorded during the conventional sternotomy operations. The clinical and echocardiographic data show very good midterm results of the reconstruction with a 100% freedom from reoperation and a stable competence of the mitral valve up to 4 years of follow-up, confirming that the minimally invasive approach in the treatment of the Barlow's disease does not impair the durability of the repair.
The expected major advantages of minimally invasive mitral valve surgery are reduced postoperative pain, decreased length of hospital stay, faster overall recovery, and improved cosmetic results [12–14]. The degree of patient satisfaction in terms of comfort and cosmesis in our series was very high. Procedure-related pain was considered very positively as well. However, the patients were interviewed about the postoperative discomfort, not immediately after surgery but at the time of follow-up, when they were extremely pleased with the aesthetic result and the prompt overall recovery obtained with the procedure. This might have influenced, more favorably, their opinion on the perioperative pain. The hospital stay was rather short and the majority of the patients were fully recovered, returning to work and resuming a normal lifestyle within 4 weeks after surgery [4, 5, 11].
We are fully aware that this study has several limitations since it is an observational study without a matched control group or a randomization. Moreover, it should be emphasized that the results could have been affected, at least in part, by the highly selected population of our series; mainly young patients with no major comorbidities, who could take the most benefit from this strategy having at the same time the lowest risk of related complications. Nevertheless, this represents an experience reporting the feasibility of a successful mitral valve reconstruction in the presence of very complex valve lesions, through a minimally invasive approach. The durability of the repair was not compromised or jeopardized by the minithoracotomy access and the level of patient satisfaction in terms of cosmetic results, postoperative pain, and time to full recovery after the operation appeared to be very high. In our opinion these results certainly justify the adoption of this strategy whenever considered feasible and, in particular, in young and active people.
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References
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Abstract
Introduction
