Ann Thorac Surg 2007;83:322-323
© 2007 The Society of Thoracic Surgeons
How To Do It
The "Hybrid Flip-Over" Technique for Anterior Leaflet Prolapse Repair
Thierry G. Mesana, MD, PhDa,*,
Moheb Ibrahim, MDa,
Alexander Kulik, MDa,
Marc Ruel, MD, MPHa,
Karen Dover, MDa,
Donna Nicholson, MDb,
Mark Hynes, MDb
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 March 27, 2006.
* Address correspondence to Dr Mesana, University of Ottawa Heart Institute, 40 Ruskin Street, Suite 3402, Ottawa, Ontario, K1Y 4W7 Canada (Email: tmesana{at}ottawaheart.ca).
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Abstract
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Repair of the anterior mitral leaflet or bi-leaflet prolapse is technically more demanding than repair of the posterior mitral leaflet. Although several techniques have been proposed for the repair of anterior mitral leaflet prolapse during bi-leaflet repair, practical challenges remain, including the determination of the appropriate length for artificial chords. Herein we describe a novel and reproducible technique for bi-leaflet mitral valve repair, including those with extensive anterior mitral leaflet prolapse.
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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]. However, repair of anterior mitral leaflet (AML) or bi-leaflet prolapse is technically more demanding than repair of the posterior mitral leaflet (PML). Several techniques have been described including the use of artificial chords. One of the challenging issues in chordal replacement is ensuring the ideal length of an artificial chord. We have developed a simple and reproducible technique that ensures the correct length of a new mitral chord. This technique is best applied in patients who require bi-leaflet repair including those with extensive AML prolapse.
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Technique
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Quadrangular resection of the posterior leaflet is first performed, leaving a strip of the leaflet attached to the posterior annulus that is 2 to 3 mm in width (Figs 1A,
1B). This strip may have basal chordae tendinea attached to it. The length of the strip can vary according to the extent of the AML prolapse and can be used to repair extensive AML prolapse involving all three segments of the anterior leaflet (A1, A2, and A3). Then 4-0 polytetrafluoroethylene Gore-Tex sutures (W.L. Gore & Assoc, Flagstaff, AZ) are passed through the apex of the papillary muscles and then into the basal strip of the PML that is left attached to the annulus (Fig 1C). The artificial chords are then tied on the atrial side of the strip without tension. This is the fundamental step that ensures optimal length of the artificial chords. Subsequently, the strip, together with the attached artificial chords and any attached basal chordae tendinea, is separated from the annulus (Fig 1D) and sutured to the free margin of the anterior leaflet with interrupted and continuous 5-0 polypropylene sutures (Fig 1E). Thereafter, the posterior leaflet repair is continued with a sliding plasty, featuring a modification of the previously described annular plication technique [2]. Two sutures of 3-0 Gore-Tex (W.L. Gore & Assoc) are run from each end of the sliding plasty on the posterior section of the annulus toward each other to plicate the annulus (Fig 1F). This is performed in a manner similar to a DeVega repair. Finally, an annuloplasty band is added to complete the repair.
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Fig 1. (A) Both the anterior mitral leaflet (AML) and the posterior mitral leaflet (PML) are prolapsed with elongated and redundant chordae from each papillary muscle. (B) The PML is resected, leaving a narrow basal strip of PML attached to the annulus. (C) The 4-0 Gore-Tex sutures (W.L. Gore & Assoc, Flagstaff, AZ) are subsequently passed through each papillary muscle and sutured to the basal strip. (D) After the Gore-Tex sutures have been tied, the strip is detached and transferred to the free edge of the AML, supporting potentially A1 to A3 (E). (F) Finally, the sliding plasty is achieved with a modified technique of annular plication using two running sutures of 3-0 Gore-Tex and an annuloplasty banded is added to complete the repair.
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We have used this technique in our last 5 patients who presented with severe mitral regurgitation secondary to bi-leaflet prolapse (ie, 3 males, 2 females; age range, 42 to 70 years). The "hybrid flip-over" technique was used to reconstruct extensive AML prolapse involving A1, A2, and A3 in 3 patients and A1 and A2 in the other 2 patients. In addition to the "hybrid flip-over" technique, each case involved the resection of the PML, a sliding plasty, and an annuloplasty band. Cross-clamp times ranged from 73 to 91 minutes. Three patients had transient episodes of atrial fibrillation, but there were no perioperative deaths, and all patients were discharged on postoperative day 5. Trivial mitral regurgitation or less was demonstrated during intraoperative transesophageal echocardiography after separation from cardiopulmonary bypass. There have been no recurrences of mitral regurgitation during early follow-up (maximum, 6-month duration).
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Comment
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Several techniques have been described to repair AML prolapse including triangular resection, plication, edge-to-edge repair, chordal shortening, chordal transfer, and chordal replacement using artificial chords. Mixed results have been reported for the anterior leaflet resection techniques [3, 4]. Although reliable if properly performed, chordal shortening at the papillary muscle level can be technically demanding. Chordal transfer from the PML with the "flip-over" technique is highly reproducible, but limited by the very frequent presence of an abnormal PML [5]. Chordal replacement with expanded polytetrafluoroethylene has gained increasing popularity because of its availability, theoretical simplicity, and long-term durability. Phillips and colleagues [6] have shown that chordal replacement with polytetrafluoroethylene is superior to chordal shortening.
The main challenge with chordal replacement is the determination of its appropriate length. Several methods to ensure the optimal length of the artificial chord have been reported. Duran and Pekar [5] suggested taking a normal nonprolapsing segment of PML as a reference point. However, in the absence of such a reference point as in cases of bi-leaflet prolapse, he advised tying the neo-chordae at the level of the plane of the annuloplasty ring. This implies that the neo-chordae must be maintained untied while all the repair maneuvers are being completed, including the placement of the annuloplasty ring. For bi-leaflet prolapse, David [7] proposed using the level of the lateral commissure in relation to the mitral annulus to estimate the length of neo-chordae, because that area is seldom involved by the degenerative process. Adams and colleagues [8] recommended deferring the tying of neo-chordae until the annuloplasty ring is in place. In his technique, the optimal chordal height is achieved by intermittent testing of valve competency with ventricular saline injections. Gillinov recently demonstrated the benefit of pre-measured artificial chordae using an intraoperative caliper in a video session (presented during the Annual Meeting of The Society of Thoracic Surgeons Meeting in Chicago, IL, January 31, 2006).
The plethora of techniques for repair of AML prolapse suggests that none of them is reproducible in all hands. The fundamental feature of our technique lies in its simplicity. The basal strip of the posterior leaflet is left attached to the annulus until the artificial chords are tied down. Thus the posterior leaflet reference point enables the chords to be tied without tension or traction on the papillary muscles and the anterior leaflet. The reference point is a strip of annulus facing the anterior leaflet and not one or two specific points, and so there is virtually no chance to misevaluate the adjustment of the opposing anterior leaflet. This leads to the typical echocardiographic features of a successful mitral valve repair, including a perfect coaptation between the leaflets, a very limited residual surface of the posterior leaflet, and the anterior leaflet free edge at the level of the annulus.
Another major feature of this technique is the fact that the basal strip may have native chordae attached to it, thereby adding extra strength to the repair. It also can be completed before posterior leaflet reconstruction and prior to the annuloplasty ring being inserted. Indeed, this technique is a hybrid of two techniques: (1) chordal replacement with Gore-Tex artificial chords (W.L. Gore & Assoc) and (2) the "flip-over" technique in which a basal strip of PML is used. Therefore we have labeled it the "hybrid flip-over" technique, indicating the hybrid use of both native mitral valve tissue and artificial chords. We believe that our technique has a much higher reproducibility compared with other techniques and it is easily teachable. The "hybrid flip-over" technique provides an excellent method to repair AML prolapse in patients with severe bi-leaflet prolapse.
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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]
- Mesana T, Ibrahim M, Hynes M. A technique for annular plication to facilitate sliding plasty after extensive mitral valve posterior leaflet resection Ann Thorac Surg 2005;79(2):720-722.[Abstract/Free Full Text]
- Letsou GV. Mitral valve repair and the anterior leaflet Curr Opin Cardiol 2002;17:179-182.[Medline]
- Saunders PC, Grossi EA, Schwartz CF, et al. Anterior leaflet resection of the mitral valve Semin Thorac Cardiovasc Surg 2004;16:188-193.[Medline]
- Duran CM, Pekar F. Techniques for ensuring the correct length of new mitral chords J Heart Valve Dis 2003;12:156-161.[Medline]
- Phillips MR, Daly RC, Schaff HV, Dearani JA, Mullany CJ, Orszulak TA. Repair of anterior leaflet mitral valve prolapse: chordal replacement versus chordal shortening Ann Thorac Surg 2000;69:25-29.[Abstract/Free Full Text]
- David TE. Artificial chordae Semin Thorac Cardiovasc Surg 2004;16:161-168.[Medline]
- Adams DH, Kadner A, Chen RH. Artificial mitral valve chordae replacement made simple Ann Thorac Surg 2001;71:1377-1378discussion 1378-9.[Abstract/Free Full Text]
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Abstract
Introduction
