Ann Thorac Surg 2006;82:e46-e48
© 2006 The Society of Thoracic Surgeons
How To Do It
Folding Valvuloplasty Without Leaflet Resection: Simplified Method for Mitral Valve Repair
Tomislav Mihaljevic, MD*,
Eugene H. Blackstone, MD,
Bruce W. Lytle, MD
Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
Accepted for publication July 26, 2006.
* Address correspondence to Dr Mihaljevic, Department of Thoracic and Cardiovascular Surgery/F24, Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH 44195 (Email: mihaljt{at}ccf.org).
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Abstract
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Standard repair techniques can prove challenging in patients with severe myxomatous mitral valve disease when there is a broad-based mid-portion of the posterior leaflet and small medial and lateral scallops. We describe a new surgical technique in which the mitral valve repair was accomplished by simple folding the prolapsed segment of the posterior leaflet and by insertion of the flexible annuloplasty ring.
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Introduction
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Mitral valve repair represents the gold standard for treatment of severe mitral regurgitation caused by degenerative mitral valve disease [1]. Prolapse of the mid-portion of the posterior leaflet represents the most common anatomical abnormality causing mitral regurgitation. Successful mitral valve repair can be performed in the majority of cases using partial leaflet resection, annular plication, or sliding valvuloplasty, and placement of the annuloplasty ring [2]. However the application of standard techniques can prove to be challenging in patients with severe myxomatous mitral valve disease with broad-based mid-portion of the posterior leaflet, and small, diminutive medial and lateral scallops. The quadrangular resection of the middle scallop leaves a large defect in the posterior annulus, which can be difficult to cover with thin and narrow remnants of the posterior leaflet.
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Technique
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We describe a new technique for the posterior leaflet repair by simple folding of the posterior leaflet while avoiding resection of the leaflet tissue. The addition of the annuloplasty ring effectively reduces the size of the annulus and completes the repair.
From February 2005 until May 2005, 5 patients (age range, 42–54 yrs; 3 men, 2 women) with severe prolapse of the broad-based middle scallop (P2) of the posterior leaflet underwent folding valvuloplasty and insertion of the flexible annuloplasty ring. All patients were in New York Heart Association’s functional class II and had no significant comorbid conditions.
The preoperative transesophageal echocardiography showed a severe flail of the posterior leaflet with the broad regurgitant jet directed in 4 patients. One patient had bi-leaflet prolapse with predominance of posterior leaflet pathology. Left ventricular function was preserved in all patients, and none of the patients had evidence of coronary artery disease on preoperative angiograms.
A minimally invasive approach with a partial upper sternotomy extending into the fourth left intercostal space was used in 4 patients. One patient underwent a complete sternotomy. Myocardial protection was accomplished with intermittent cold blood cardioplegia. The mitral valve was approached through a transseptal incision. The inspection of the mitral valve showed a myxomatous valve disease with a dilated annulus and P2 prolapse in all patients. The mid-portion of the posterior leaflet was tall with a very broad base covering more than a half of the total length of the posterior part of the mitral valve annulus (Fig 1). Several cords of the prolapsed segment were ruptured. One patient had associated prolapse of the medial portion of the lateral (P1) scallop, and one patient had a mild anterior leaflet prolapse. The medial and lateral scallops were small with a small, narrow base and thin leaflet tissue.
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Fig 1. Top: view of the prolapsed middle scallop with ruptured chordae from the surgeon’s view. Bottom: Prolapse of the broad-based middle scallop of the posterior leaflet of the mitral valve with diminutive lateral and medial scallop.
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Repair of the posterior leaflet was performed with three mattressed 2-0 nonabsorbable sutures (Ethibond [Ethicon Inc, Somerville, NJ]), which were placed along the free edge of the prolapsed mid scallop (Fig 2). The sutures were than passed through the mid-portion of the mitral valve annulus, causing the mid-scallop to fold onto itself, effectively reducing its height to approximately 1 cm. The same sutures were then used to anchor the mid-portion of the flexible annuloplasty ring (Cosgrove, Edwards Annuloplasty System [Edwards Lifesciences, Irvine, CA]) (Fig 3). We then placed the remaining annuloplasty sutures through the lateral and medial portions of the posterior part of the mitral annulus. The size of the annuloplasty ring was based on the size of the anterior leaflet and inserted into place (34-mm ring, 4 patients; 38-mm ring, 1 patient). Valve competence was confirmed by administration of antegrade cardioplegia, and the transseptal incision was closed with a running nonabsorbable suture.
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Fig 2. Top: Placement of the mattressed sutures through the edge of the prolapsed segment of the posterior leaflet. Bottom: Folding of the prolapsed portion of the posterior mitral valve leaflet by series of horizontal mattressed sutures with resultant reduction in the height of the posterior leaflet.
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Fig 3. Top: Folding sutures are used to anchor the partial annuloplasty ring. Bottom: Completed repair with reduction of the height of posterior leaflet and inserted annuloplasty ring.
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The postoperative course was uneventful in all patients with an average hospital stay of 5 days. Postoperative echocardiograms showed a competent mitral valve with no residual mitral regurgitation in 4 patients, and mild residual mitral regurgitation in 1 patient.
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Comment
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Mitral valve repair with standardized techniques offers adequate solution for the majority of patients with typical forms of degenerative disease. The success of reconstructive mitral valve surgery is primarily based on the correct choice of a surgical technique that can correct an anatomic abnormality of each individual patient. Patients with the prolapse of the posterior leaflet and the broad-based middle scallop represent a surgical challenge, because the use of standard techniques may not be adequate to correct the problem.
The standard surgical approach includes quadrangular resection of the entire diseased segment of the posterior leaflet, followed by sliding valvuloplasty or annular placation, or both [2]. However, in patients with broad-based mid-scallop of the posterior leaflet the resection would result in a very large defect in the posterior leaflet, which would needed to be covered by typically narrow-based and thin remaining portions of the posterior leaflet. Extensive sliding valvuloplasty represents a potential solution; however, stretching of very thin medial and lateral scallops over a large defect can result in leaflet tear and subsequent residual regurgitation. The aggressive plication of the annulus offers an alternative that can result in the distortion of the annulus and kinking of the circumflex artery [3]. Edge-to-edge repair would be difficult in these patients due to the broad segment of the prolapsed posterior leaflet, which would create the need for a wide apposition suture with consequent risk of mitral stenosis. Recent reports have involved the description of more complex solutions to this problem, which include partial placation of the leaflet combined with placement of multiple artificial chordae [4].
The described technique represents a simple solution for patients with severe degenerative disease of the mitral valve and with broad-based mid-scallop of the posterior leaflet. Folding of the posterior leaflet effectively reduces the height of the posterior leaflet. Preserved secondary chords and the anchored free margin of the posterior leaflet to the annulus secure its stable position and prevent backfolding into the left atrium during systole. Although the folding of the leaflet causes minor distortion of the secondary chordae this does not appear to influence the reproducibility of the repair. Downsizing of the annular diameter with an annuloplasty ring allows effective "uni-cuspidalization" of the mitral valve, in which the anterior leaflet is largely responsible for the effective opening and closing of the mitral valve orifice. Therefore the size of the annuloplasty ring is determined based on the surface of the anterior leaflet rather than on inter-trigonal distance. The function of the folded posterior leaflet is reduced to a passive shelve against which the mobile anterior leaflet closes during systole.
The simplicity of this technique makes it a potentially attractive alternative to established traditional techniques, in particular for minimally invasive, endoscopic, and robotic procedures in which the quadrangular resection and sliding valvuloplasty are time-consuming and technically challenging [5]. Another potential advantage of this technique is its reversibility. In the case of failed repair, the folding valvuloplasty can be undone, and an alternative technique can be applied.
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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]
- 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]
- 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]
- Calafiore AM, Di Mauro M, Actis-Dato G, et al. Longitudinal plication of the posterior leaflet in myxomatous disease of the mitral valve Ann Thorac Surg 2006;81:1909-1910.[Abstract/Free Full Text]
- Nifong LW, Chitwood WR, Pappas PS, et al. Robotic mitral valve surgery: a United States multicenter trial J Thorac Cardiovasc Surg 2005;129:1395-1404.[Abstract/Free Full Text]
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Abstract
Introduction
