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Ann Thorac Surg 2006;81:1909-1910
© 2006 The Society of Thoracic Surgeons

How to do it

Longitudinal Plication of the Posterior Leaflet in Myxomatous Disease of the Mitral Valve

Antonio M. Calafiore, MD * , Michele Di Mauro, MD, Guglielmo Actis-Dato, MD, Angela Lorena Iacò, MD, Paolo Centofanti, MD, Piero Forsennati, MD, Francesco Patanè, MD, Lorena Di Gioacchino, MD

Division of Cardiac Surgery, University Hospital, Torino, Italy

Accepted for publication February 23, 2005.

* Address correspondence to Dr Calafiore, Division of Cardiac Surgery, S Giovanni Battista Hospital, c.so Bramante 86, Torino, Italy (Email: calafiore{at}unich.it).


   Abstract
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 Abstract
Introduction
 Technique
 Comment
 References
 
In selected cases, resection of a prolapsing scallop of the posterior leaflet (generally P2) is not advisable because of the excessive length of insertion of the scallop. In such cases, insertion of artificial chordae is advisable, but the height of the scallop needs to be reduced. We used longitudinal plication of the scallop(s) in which the height was excessive with "U" sutures in 11 consecutive patients. Early and intermediate echocardiographic results were fully satisfying, and we expect that the morphologic aspect of the repaired mitral valve will remain stable after a longer follow-up.


   Introduction
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 Abstract
 Introduction
Technique
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Prolapse of the central scallop of the posterior leaflet (P2) is generally corrected with quadrangular resection, as proposed by Carpentier [1], followed by annular plication with or without sliding of the posterior leaflet [2]. In some cases the lateral edges of P1 and P3 are directly sewed to the annulus [3]. To avoid an excessive annular plication, when the insertion of P2 is superior to one third of the posterior annulus some authors proposed to avoid its resection and to use the artificial chordae [4]. We follow this suggestion, as plication of the posterior annulus can have some harmful effects [5]. There is no particular problem when the height of P2 is normal. In case of myxomatous disease of the mitral valve, the excess in length of P2 has to be reduced. In this latter situation, we longitudinally plicate P2 (or other scallops with tissue in excess) to quickly obtain a correct reduction of the height of the prolapsing myxomatous scallops.


   Technique
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Starting in December 2003, 11 consecutive patients with myxomatous degeneration of the posterior leaflet underwent longitudinal plication of the scallops with tissue in excess.

The prolapsing scallops of the posterior leaflet were P2 in 2 patients, P2 and P3 in 4, P1 and P2 in 1, and all three scallops in 4. The anterior leaflet was involved in 4 patients. Mean scallop involvement per patient was 2.6 ± 1.0, whereas 5 patients had three or more prolapsing scallops.

All the patients were operated by using a median sternotomy approach. The arterial inflow was always the ascending aorta, and both venae cavae were directly cannulated. The approach to the mitral valve was always transseptal. Myocardial protection was achieved with intermittent antegrade warm blood cardioplegia [6]. Perioperative transesophageal echocardiogram was obtained in all the patients.

After a careful examination of the anatomy of the mitral valve, longitudinal plication of the scallops with tissue in excess was obtained with three to six interrupted "U" sutures (Prolene 4-0 [Ethicon, Somerville, NJ]), passed from the annulus to the mid portion of the scallop. The purpose of this technique was to reduce the height of the scallop to normal values (Fig 1). The artificial chordae were then passed where necessary. An over-reduction ring (Sorin [Saluggia, Torino, Italy]) was positioned in all the cases, 40-mm long in 7 patients (SMB40 [Sorin Miniband]) and 50-mm long in the remaining 4 (SMB50).


Figure 1
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  		Fig 1. (A) Three "U" sutures are passed in the prolapsing scallop in which the height has to be reduced. (B) The sutures are then tied. (C) Sagittal view.

 
All the patients were followed-up at our outpatient clinic. A postoperative echocardiogram was performed in all cases. The follow-up was 100% complete.

The number of chordae per patient in the posterior leaflet was 7.6 ± 4.8. In the 4 patients in which the anterior leaflet was prolapsing, the number of chordae used for the anterior leaflet per patient was 6.5 ± 2.0. No patient had residual mitral regurgitation or systolic anterior motion at the end of the procedure. The echocardiographic aspect of the mitral valve after posterior leaflet longitudinal plication was indistinguishable after repair was obtained with different techniques (Fig 2). No patient died or had major complications.


Figure 2
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  		Fig 2. Transesophageal echocardiograms after plication of all three scallops of the posterior leaflet.

 
After a mean follow-up of 5 ± 4 months, no patient showed echocardiographic evidence of mitral regurgitation.


   Comment
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Mitral valve repair is the procedure of choice for degenerative mitral regurgitation. At the end of the procedure, we needed to have not only a continent mitral valve, but also a posterior leaflet of normal height, because a redundant posterior leaflet can be one of the anatomical components of the systolic anterior motion, which is a complication in 1% to 6% of the cases [7]. This is the case of the myxomatous mitral valve in which redundancy is the anatomical base of the disease.

Resection of the prolapsing posterior scallop, generally P2, is the procedure of choice. However, if its annular insertion is wide, its resection is followed by an excessive plication of the posterior annulus with possible distortion of a dominant circumflex artery [5]. In this case, if the height of P2 is normal, the artificial chordae can be directly implanted. However, if P2 is too high, its longitudinal plication allows to easily shorten the dimension of P2. This procedure can be applied to all of the scallops with tissue in excess for the same purpose.

The echocardiographic results are excellent and, even if a longer follow-up is needed, we expect that the morphology of the repaired mitral valve will remain stable in time.


   References
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 Abstract
 Introduction
 Technique
 Comment
 References
 

  1. Carpentier A. Cardiac valve surgerythe French correction. J Thorac Cardiovasc Surg 1983;86:323-337.[Medline]
  2. Perier P, Clausnizer B, Mistarz K. Carpentier sliding leaflet technique for repair of the mitral valveearly results. Ann Thorac Surg 1994;57:383-386.[Abstract]
  3. Grossi EA, Galloway AC, Kallenbach K, et al. Early results of posterior leaflet folding plasty for mitral valve reconstruction Ann Thorac Surg 1998;65:1057-1059.[Abstract/Free Full Text]
  4. Nigro JJ, Schwartz DS, Bart RD, et al. Neochordal repair of the posterior mitral leaflet J Thorac Cardiovasc Surg 2004;127:440-447.[Abstract/Free Full Text]
  5. Tavilla G, Pacini D. Damage to the circumflex coronary artery during mitral valve repair with sliding leaflet technique Ann Thorac Surg 1998;66:2091-2093.[Abstract/Free Full Text]
  6. Calafiore AM, Teodori G, Mezzetti A, et al. Intermittent antegrade warm blood cardioplegia Ann Thorac Surg 1995;59:398-402.[Abstract/Free Full Text]
  7. Civelek A, Szalay Z, Roth M, et al. Post-mitral valve repair systolic anterior motion produced by non-obstructive septal bulge Eur J Cardio-Thorac Surg 2003;24:857-861.[Abstract/Free Full Text]



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This Article
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Michele Di Mauro
Francesco Patanè
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Right arrow Valve disease

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