Ann Thorac Surg 2007;83:1560-1561
© 2007 The Society of Thoracic Surgeons
How To Do It
Anterior Mitral Leaflet Augmentation With Autologous Pericardium
Stéphane Aubert, MD, MS*,
Erwan Flecher, MD,
Sylvain Rubin, MD,
Christophe Acar, MD,
Iradj Gandjbakhch, MD
Department of Cardiothoracic Surgery, La Pitié Salpêtrière Hospital, Paris, France
Accepted for publication May 16, 2006.
* Address correspondence to Dr Stephane Aubert, Department of Cardiovascular Surgery, Pitié Salpêtrière Hospital, 47-83 Boulevard de l’hôpital 75651 Paris, Cedex 13 France (Email: stephaneaubert{at}yahoo.fr).
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Abstract
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The results of mitral repair for rheumatic valve insufficiency are still suboptimal. Anterior leaflet augmentation with autologous pericardium is a useful adjunct to compensate leaflet and chordae retraction. The technique and its indication are described in this article.
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Introduction
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The long-term results of mitral repair for rheumatic valve insufficiency are still suboptimal. In spite of undersized annuloplasty, persistence or recurrence of mitral regurgitation can occur due to severity of tissue retraction precluding leaflet coaptation (Carpentier type IIIa).
The use of autologous pericardium patches briefly fixed with glutaraldehyde in mitral repair offers durable results with no calcification or retraction [1]. It has been applied successfully for anterior leaflet augmentation in case of rheumatic mitral valve insufficiency [2]. This article describes the technique and its indications.
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Technique
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Between 1997 and 2005, 90 patients (70 females, 20 males) underwent anterior mitral leaflet augmentation with autologous pericardium for Carpentier type IIIa insufficiency. The mean age was 43 ± 16 years (range, 10 to 82 years). The mode of dysfunction was pure mitral insufficiency in 71 cases (78.9%) and insufficiency associated with stenosis in 19 cases (21.1%). The cause was a rheumatic valve disease in 82 patients and retraction from another cause (ie, autoimmune disease or unknown) in 8 cases. Mitral annuloplasty was performed with a flexible ring in 65 cases and with a rigid ring in 16 cases. No annuloplasty was achieved in 9 cases. The mean ring size was 27.7 ± 1.2 mm for Duran rings (Medtronic Inc, Minneapolis, MN) and 30.6 ± 1.9 mm for Carpentier rings (Edwards Lifesciences LLC, Irvine, CA). In addition, the following techniques were used: commissurotomy (n = 51) and chordae fenestration (n = 8). If necessary the chords were spared longitudinally with a knife (blade 11) from the free edge of the leaflet toward the papillary muscle. Associated procedures included tricuspid annuloplasty (n = 8), Cox-maze procedure (n = 14), Ross procedure (n = 4), aortic valve replacement (n = 6) and coronary artery bypass grafting (n = 4). The mean aortic clamp time and cardiopulmonary bypass time were 74.5 ± 19.4 minutes and 84.9 ± 22.9 minutes, respectively. Intraoperative transesophageal echocardiography analysis of the result was performed in all cases.
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Surgical Technique
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After the median sternotomy a large piece of pericardium was freed from any pleural or mediastinal adhesion and harvested. The piece of pericardium was carefully unfolded on a sponge and dipped into a bath of 0.6% glutaraldehyde solution for a 15-minute period [3, 4]. It was then rinsed in a saline bath.
Using the standard approach through the interatrial groove, the mitral valve was exposed and the lesions were analyzed. The anterior leaflet was measured using a ring sizer. If the degree of leaflet retraction did not safely allow the downsizing of the annuloplasty ring by two sizes (ie, risk of stenosis), it was decided to apply the anterior leaflet augmentation technique. To avoid any damage to the pericardial patch suture, all stitches devoted to prosthetic ring annuloplasty (2-0 Ethibond [Ethicon Inc, Piscataway, NJ]) were placed before anterior leaflet augmentation.
An incision was performed at the base of the anterior leaflet extending from one commissure to the other. Care was taken to avoid tearing the commissural tissue, which should be detached from the annulus at the level of the trigones. The incision ran through the anterior leaflet tissue remaining at 2 mm away from the mitral annulus (Fig 1).
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Fig 1. The base of the anterior leaflet is detached and the length of the incision (L) is measured. Sutures for prosthetic ring annuloplasty have been already placed.
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The length (L) of the incision was measured by means of a ring obturator (Fig 1). Using the same ring sizer, the ovoid shape of the patch was outlined with a permanent marker (Fig 2). The patch was then tailored taking care to avoid any undersizing (following the external limit of the mark). The piece of pericardium was then fixed using a 5-0 polypropylene running suture starting from the posteromedial commissure. It progressed counterclockwise along the annulus until the midpart of the anterior leaflet and was then completed clockwise using the other braid (Fig 3). Once enlarged, the new dimensions of the anterior leaflet were measured using an appropriate sizer. Prosthetic ring annuloplasty was then achieved using a slight downsizing (ie, one size down as compared with the anterior leaflet) (Fig 4).
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Fig 2. (1) The flat side of a ring obturator is used to outline with a marker the limits of the patch. (2) The obturator is flipped so as to obtain an ovoid shape. The pericardium is then tailored accordingly.
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Fig 3. The piece of pericardium is sutured to the valve with a 5-0 Prolene running suture (Ethicon, Somerville, NJ) starting with the posteromedial commissure.
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Fig 4. Prosthetic ring annuloplasty is performed according to a slight downsizing so as to achieve a perfect leaflet coaptation.
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Comment
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Together with valve rigidity due to calcification, which usually leads to valve replacement, the severity of tissue retraction involving both the leaflets and the chordae is the main pitfall for valve repair in case of rheumatic mitral disease. To compensate tissue retraction, the aforementioned technique of anterior leaflet augmentation has been shown to be safe and reproducible [2]. As described, the enlargement concerned not only the anterior leaflet but also the commissural areas. The echocardiography study has shown that the anterior leaflet mobility and the surface of leaflet coaptation were significantly increased. In addition, it allowed the insertion of a larger annuloplasty ring, thereby reducing the risk for stenosis. Massive calcified mitral annulus and subvalvular apparatus may represent a real limit to perform this technique. Careful follow-up will confirm whether a wide use anterior leaflet augmentation substantially improves mid-term and long-term outcome of valve repair in rheumatic mitral valve disease.
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References
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- Chauvaud S, Jebara V, Chachques JC, et al. Valve extension with glutaraldehyde-preserved autologous pericardiumResults in mitral valve repair. J Thorac Cardiovasc Surg 1991;102:171-177discussion 177–8.[Abstract]
- Acar C, de Ibarra JS, Lansac E. Anterior leaflet augmentation with autologous pericardium for mitral repair in rheumatic valve insufficiency J Heart Valve Dis 2004;13:741-746.[Medline]
- Carpentier A. Cardiac valve surgery—the "French correction" J Thorac Cardiovasc Surg 1983;86:323-337.[Medline]
- Chachques JC, Perrier P, Balansa J, Chauvaud S, Carpentier A. A rapid method to stabilize biological materials for cardiovascular surgery Ann NY Acad Sci 1988;529:184-186.
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Abstract
Introduction
