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Ann Thorac Surg 2005;80:1315-1318
© 2005 The Society of Thoracic Surgeons

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Original article: Cardiovascular

Edge-to-Edge Repair With Mitral Annuloplasty for Barlow's Disease

Department of Cardiac Surgery, Glenfield Hospital, University of Leicester, Leicester, United Kingdom

Accepted for publication March 4, 2005.

^_* Address reprint requests to Dr Alexiou, Department of Cardiac Surgery, Glenfield Hospital, Leicester LE3 1QP, UK (Email: alexiou486{at}aol.com).

	Abstract

Top Abstract Introduction Patients and Methods Results Comment References

 
BACKGROUND: The purpose of this study was to define the early and midterm results obtained after the use of edge-to-edge repair with mitral annuloplasty in the setting of Barlow's disease.

METHODS: Between 1998 and 2004, 41 patients having Barlow's disease had an edge-to-edge repair creating a double-lumen mitral valve orifice in our unit. In 38 patients (93%), an annuloplasty band was also inserted.

RESULTS: Preoperatively, all patients had severe mitral regurgitation (MR), 12 were in New York Heart Association (NYHA) class I, 15 in class II, and 14 in class III. One patient died in hospital (2.4%) and 5 experienced complications (12.5%). There were no late deaths. At follow-up, 2 patients had severe MR and underwent valve replacement, 1 exhibited moderate MR, and 5 had mild MR. Kaplan-Meier 5-year survival, freedom from reoperation and recurrent moderate-severe MR was 97.6% ± 2.4%, 94% ± 4.4%, and 90.6% ± 5.1%, respectively. At latest echocardiographic evaluation (mean 35 ± 12 months) the mean left ventricular end-systolic and end-diastolic diameters, and the mitral valve area decreased (p = 0.0001) compared with baseline. The mean mitral valve gradient increased (p = 0.001) without clinical evidence of mitral stenosis whereas ejection fraction did not change. Currently, 35 patients are in NYHA class I and 5 are in class II.

CONCLUSIONS: In the setting of Barlow's disease, use of edge-to-edge repair with mitral annuloplasty is safe and provides lasting restoration of mitral valve competence with measurable hemodynamic and clinical benefits. In our unit, it is the procedure of choice for correction of MR in patients having Barlow's disease.

	Introduction

Top Abstract Introduction Patients and Methods Results Comment References

 
Barlow's disease (or billowing mitral leaflet syndrome) is a degenerative mitral valve (MV) disorder characterized by excessive leaflet tissue with myxoid appearance and leaflet billowing leading eventually to the development of mitral regurgitation (MR) [1]. Barlow's disease may be identified in as many as 30% of patients undergoing MV repair for mitral regurgitation due to leaflet prolapse. In the majority of patients both leaflets are prolapsing [1].

The traditional treatment of this pathologic entity involved complex types of mitral valve repair or mitral valve replacement. However, MV repair in the setting of Barlow's disease can be challenging and is associated with a higher risk for reoperation [2]. In 1995, Fucci and colleagues [3] described a new approach, the edge-to-edge type of repair that creates a double-orifice MV for the management of MR of various etiologies. Although this simplified technique is now accepted as a useful addition to the preexisting types of repair, its durability has not been well established.

In this paper, we describe the early and midterm clinical and echocardiographic results obtained after the use of the central edge-to-edge technique, combined with mitral annuloplasty, to repair regurgitant mitral valves in patients with Barlow's disease.

	Patients and Methods

Top Abstract Introduction Patients and Methods Results Comment References

 
Between 1998 and 2004, a total of 662 patients underwent MV repair procedures at Glenfield Hospital, Leicester. Forty-one of these patients who had Barlow's disease with bileaflet prolapse and underwent a central edge-to-edge type of MV repair are the subjects of this report. There were 29 male and 12 female patients with a mean age of 58 ± 8 years (range, 45 to 69). In 38 of these patients (93%), a Cosgrove-Edwards annuloplasty band was also inserted. Over the study period, this was the only type of repair used for Barlow's disease in our institution. It is likely, however, that some patients with this pathologic entity were treated with primary MV replacement.

The diagnosis of Barlow's disease was suggested preoperatively on two-dimensional transthoracic echocardiography and confirmed intraoperatively. Coronary angiography was performed in all patients.

Operative Techniques
Transoesophageal echocardiography (TOE) was used routinely in the perioperative period. Median sternotomy, normothermic cardiopulmonary bypass (37°C), and antegrade or retrograde warm blood cardioplegia were used. The MV was accessed through the left atrium. If tricuspid valve surgery was also undertaken a transeptal approach was used. After inspection of the MV apparatus and confirmation of diagnosis of Barlow's disease, a central edge-to-edge repair was performed creating a double-orifice MV as described by Maisano and colleagues [4]. In brief, the central part of the anterior and posterior leaflet was identified using valve hooks and marked with a 4-0 polypropylene stay suture. Then a two-layered 3-0 polypropylene nonpledgeted mattress suture was run across the central parts of the two leaflets. The distance of the two suture bites from each leaflet edge was approximately 15 mm and 5 mm, aiming to create an area of leaflet coaptation of approximately 5 mm to 10 mm long. In the absence of severe annular calcification, a Cosgrove-Edwards annuloplasty band was inserted to support the repair, reduce the annulus, and prevent further annular dilatation. The size of the two orifices was measured after completion of the annuloplasty with Hegar dilators ensuring that the cumulative orifice area was above 3 cm². In cases of tricuspid valve repair a Cosgrove-Edwards annuloplasty band was also used. The MV repair was accepted if on postoperative TOE there was up to mild residual MR and the peak MV gradient was less than 8 mm Hg.

Follow-Up
After hospital discharge the patients were seen periodically in the outpatient clinics by surgeons and cardiologists where they had a clinical examination, a 12-lead electrocardiogram, and a chest radiograph. Echocardiograms were performed approximately once a year or more frequently if clinically indicated. Data were collected from the departmental database and the patient case notes. Follow-up was complete.

Statistical Analysis
Continuous variables are expressed as mean values ± SD, and the proportions as percentages. Categoric variables are compared with ²or Fisher's exact test, and continuous variables with an unpaired Student t test. Freedom from recurrent MR (moderate or severe), reoperation and survival were calculated with the Kaplan-Meier method. A p value of 0.05 or less was considered statistically significant. Statistical analysis was performed on SPSS software (version 11; SPSS, Chicago, Illinois).

	Results

Top Abstract Introduction Patients and Methods Results Comment References

 
Preoperative Clinical Profile
The mean New York Heart Association (NYHA) class for all patients was 2.04 ± 0.8. Twelve patients were asymptomatic (NYHA I), 15 were in NYHA class II, and 14 were in NYHA class III. Eleven patients (27%) had symptoms of angina, 13 (32%) were in atrial fibrillation, and the remaining were in sinus rhythm. Fourteen patients (34%) had a history of hypertension, 7 (17%) had diabetes mellitus, and 1 had suffered a previous stroke (2.4%). Seven (17%) patients had concomitant coronary artery disease and 3 (7%) had severe tricuspid regurgitation. The mean Parsonnet score was 9 ± 5 and the mean Euroscore was 4 ± 1.

Surgery
As already mentioned, a central edge-to-edge repair resulting in a double-orifice mitral valve was performed in all cases. A Cosgrove-Edwards annuloplasty band was inserted in 38 patients. In the remaining 3 patients, a band was not used owing to severe annular calcification. The mean size of the inserted annuloplasty bands was 36 ± 2 mm. On-table TOE at the completion of the procedure showed no MR in 30 patients (73%), mild MR in 7 (17%), and trivial MR in 4 (10%). Concomitant procedures included coronary artery bypass grafting (CABG) in 5 patients and tricuspid valve repair in 3. The mean aortic cross-clamp and cardiopulmonary bypass times were 44 ± 12 minutes and 57 ± 11 minutes, respectively.

Clinical Outcome and Echocardiographic Data
One patient who underwent concomitant tricuspid valve repair and CABG died of low cardiac output syndrome 18 days postoperatively, giving an early mortality of 2.4%. In addition, 5 patients (12.5%) sustained postoperative complications. These were pneumonia (2), transient ischemic attack (1), and complete heart block requiring the insertion of permanent pacemaker (2). The mean length of stay in the intensive care unit and the hospital was 2 ± 1 and 12 ± 4 days, respectively. There were no late deaths. Kaplan-Meier survival at 5 years was 97.6% ± 2.4% (Fig 1).

View larger version (14K): [in this window] [in a new window]   Fig 1. Kaplan-Meier 5-year freedom from moderate or severe mitral regurgitation (MR), reoperation, and survival was 90.6% ± 5.1%, 93.7% ± 4.4%, and 97.6% ± 2.4%, respectively.

Detailed preoperative and postoperative echocardiographic data are shown in Table 1. A significantly lower proportion of patients had MR postoperatively (p < 0.0001). The degree of MR was reduced from a mean preoperative value of 3.54 ± 0.86 to 0.58 ± 0.29 (p < 0.0001). Left ventricular end-systolic diameter (LVESD) and left ventricular end-diastolic diameter (LVEDD) were significantly reduced, but ejection fraction and fractional shortening changed only marginally (Table 1). While the MV orifice area fell significantly, the MV gradient rose. This rise, however, was not accompanied by clinical evidence of mitral stenosis. At clinical follow-up the mean NYHA class score was 1.33 ± 0.55, with 35 patients being in NYHA class I and 5 in class II (compared with preoperative state, p < 0.0001).

	Comment

Top Abstract Introduction Patients and Methods Results Comment References

Although the spectrum of degenerative MV pathology encompasses both fibroelastic deficiency and Barlow's disease, the latter represents an advanced stage of the myxomatous degenerative process in which chordal and papillary muscle elongation are compounded by polylobular free leaflet edges with increased number of clefts, annular dilatation, and deformity leading to multiple regurgitant jets. In previous studies, advanced myxomatous changes of the MV leaflets that required complex types of repair have been associated with increased risk of reoperation [2, 8]. In a series of 1,072 patients twho underwent primary isolated repair for degenerative MR, Gillivov and associates [9] showed that anterior leaflet prolapse, valvular calcification, chordal shortening, leaflet resection, or annuloplasty alone severely jeopardize the durability of repair. Of course, repair of MR due to Barlow's disease with the use of Carpentier techniques [7] can be successful, but it is technically demanding and requires prolonged ischemic time that may not be well tolerated by a sick patient [10]. For these reasons, many surgeons prefer to replace these valves.

The edge-to-edge technique was introduced by Alfieri in 1992 to simplify the repair specifically in the presence of anterior leaflet prolapse. The technique was subsequently modified to address features of Barlow's disease. The central double-orifice repair aims to correct leaflet redundancy, to force leaflet coaptation, and reduce their height to prevent postoperative systolic anterior motion, which may complicate 3% of repairs for degenerative MR [2]. Of note, in the present series, no patient developed systolic anterior motion postoperatively.

Although the edge-to-edge repair is more frequently performed for bileaflet prolapse, it has been also used in a variety of MV abnormalities including anterior leaflet prolapse, posterior leaflet prolapse, annular calcification, ischemic MR, and as a bail-out procedure after failure of standard repair techniques. Therefore, most published series reporting results of the edge-to-edge repair include patients having various MV pathologies [4, 11, 16, 17]. We have focused on patients having Barlow's disease.

This study confirms that Alfieri repair with the addition of a ring annuloplasty in patients having Barlow's disease is a simple, short (mean ischemic time 44 minutes), and effective procedure that carries minimal morbidity and low and late mortality as evidenced by the observed 5-year survival of 97.5% ± 2.4%. The 5-year freedom from reoperation of 94% ± 4.4% is satisfactory and compares favorably with the 86% ± 14% reported in the largest previously published series [4]. Information on the recurrence rate of MR after the use of edge-to-edge technique is limited. The 90.6% ± 5.1% freedom from moderate to severe MR at 5 years in this series would seem to be acceptable for this rather difficult group of patients.

Little is also known on the midterm hemodymanic effects of the edge-to-edge technique with ring annuloplasty applied in Barlow's disease. Echocardiographic follow-up in the present series revealed a positive impact of this type of repair on a number of functional and anatomic parameters brought about through a lasting restoration of MV competence. These include a reduction in the left ventricular end-systolic and end-diastolic diameters with preservation of the left ventricular contractility.

Although the edge-to-edge repair has been in use for almost a decade, concerns are still raised with regard to the risk of developing functional mitral stenosis postoperatively [11]. As would have been expected, we observed a statistically significant decrease in the MV area and a concomitant increase in the mean transvalvar gradient. However, this did not appear to cause clinically significant mitral stenosis. A limitation of this study is that the postoperative echocardiograms were performed at rest, and therefore it is not known whether patients would exhibit higher gradients and symptoms of stenosis during exercise. Nevertheless, 87.5% of the patients in our group were in NYHA class I at follow-up, leading a normal lifestyle, which does not suggest the presence of significant stenosis. Besides, it has been documented that the hemodynamic behavior of a double-orifice MV does not differ from that of a physiologic valve of the same total area. Therefore, if the postoperative MV area is above 2.5 cm², no mitral stenosis should be appreciated [12]. As mentioned above, after construction of the double-orifice MV and insertion of the annuloplasty ring, we use Hegar dilators to ensure that the effective mitral valve orifice area of the double-orifice mitral valve is greater than 3 cm². Moreover, animal experimental work showed that dobutamine stressing decreased end-diastolic valve area by 19% after edge-to-edge repair, yet only a small increase in the valve gradient occurred [13]. In another study where edge-to-edge repair was compared with MV replacement, the mean MV gradient was higher in patients who underwent replacement [14].

The resilience of the edge-to-edge repair in relation to the suture tension has also been questioned. However, previous work has shown that in this type of repair the tension on the leaflets is primarily determined by the mitral annular size and in particular the septolateral dimension and has been postulated that insertion of annuloplasty ring prevents this phenomenon [15]. In this study, 1 patient had suture dehiscence. We assume that this may be related to technical factors such as the depth of suturing or the use of a too large annuloplasty band, although it would be impossible to draw conclusions on the basis of a single patient.

In conclusion, this study shows that the edge-to-edge repair supported by a ring annuloplasty is a safe technique that provides lasting restoration of MV competence with measurable hemodynamic and clinical benefits. The postrepair transvalvular gradient increases, but with no clinically evident mitral stenosis. In our unit, the edge-to-edge repair with a ring annuloplasty is the procedure of choice for correction of MR in the setting of Barlow's disease.

	References

Top Abstract Introduction Patients and Methods Results Comment References

 

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