Ann Thorac Surg 2007;84:306-308
© 2007 The Society of Thoracic Surgeons
How To Do It
"Z-Plasty Suture": A New Procedure for Complex Reconstructions of Posterior Mitral Leaflet
Renato Bellitti, MDa,
Pasquale Santé, MD, FETCSa,*,
Giovanni Dialetto, MDa,
Franco E. Covino, MDa,
Diana Iarussi, MDb,
Gaetana Messina, MDb,
Lucio Maresca, MDa
a General Cardiac Surgery Department, Monaldi Hospital, University of Naples II, Naples, Italy
b Cardiology Department, Monaldi Hospital, University of Naples II, Naples, Italy
Accepted for publication September 1, 2006.
* Address correspondence to Dr Santé, Cardiothoracic Surgery Department, Monaldi Hospital, University of Naples II, Naples, Via G. Gigante no 7, Naples, 80136, Italy (Email: pasquale.sante{at}fastwebnet.it).
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Abstract
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In recent years the conservative techniques to treat degenerative mitral valve insufficiency have developed to such an extent mainly due to a better understanding of the physiology and pathology of the mitral valve and to the possibility to get predictable and satisfactory results. Still a challenge persists for the cardiac surgeon when he has to deal with complex reconstructions. The technique described seems to offer an even better surgical option for patients with complex lesions involving the posterior mitral leaflet, especially as far as the hemodynamic performance is concerned.
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Introduction
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It must be kept in mind that mitral valve reconstructive surgery can be basically performed through [1]: (1) anatomical reconstruction (without prosthetic material, with autologous pericardial rings); (2) reconstruction with prosthetic material (ie, artificial chordae [W.L. Gore & Assoc, Flagstaff, AZ], prosthetic rings); and (3) functional reconstruction (edge-to-edge technique).
As far as the anatomical reconstruction for degenerative mitral valve insufficiency is concerned, the procedures performed have had the purposes of not to use prosthetic material, to preserve the annular size, shape, and the inter-papillary muscles distance, and to preserve the left ventricular inlet. Accordingly, the edge-to-edge technique was strictly limited to the paracommissural prolapse to maintain the bileaflet configuration and the central flow through the mitral valve.
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Technique
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From 2003 to 2006, 98 patients were operated on for anatomical reconstruction of degenerative mitral valve insufficiency at the General Cardiac Surgery Department of the Second University of Naples. Seventy patients had a linear reconstruction of the posterior leaflet and annulus (posterior mitral leaflet prolapse [PMLP] [16 patients]; anterior mitral leaflet prolapse [22 patients]; bi-leaflet prolapse [32 patients]). Three patients had a paracommissural edge-to-edge technique. Twenty-five patients underwent a "Z-plasty suture" (posterior mitral leaflet prolapse, 18 patients, bi-leaflet prolapse, 7 patients), which is a new procedure for complex reconstructions of the posterior mitral leaflet. There were 14 males and 11 females for the latter procedure, with a mean age of 62 ± 11 years, and all of them were on sinus rhythm (5 patients were hypertensive, 9 were diabetic, 1 had chronic renal failure and none suffered ischemic cardiomyopathy. Coronary angiography was performed in all 25 respective patients. As far as the New York Heart Association functional classification was concerned, 1 patient was in class I, 23 were in class II, and 1 was in class IV with an assisted emergency ventilation.
Essentially the prerequisites for the Z-plasty suture were: (1) anterior, posterior, or bi-leaflet (not paracommissural) prolapse; (2) normal or not excessively dilated annulus; (3) normal or hypertrophic septum-posterior wall; (4) normal interpapillary muscles distance; and (5) not dilated left ventricle.
According to the posterior mitral leaflet scallops characteristics, patients were divided as follows: type 1—P2 prolapse with normal P1-P3 (7 patients); type 2—P2 giant prolapse with P1–P3 hypoplasy (15 patients); and type 3—P2 prolapse with P1-P3 redundancy (3 patients).
The surgical technique was the same in type 1 and type 2: a quadrangular resection of medial or lateral P2 was performed, limited to the segment of chordal rupture or major elongation; medial or lateral P2 was 90° translated on annulus with apex to P1 or P3 contralateral junction with the annulus; P1 or P3 were translated on the free edge of the translated medial or lateral P2; P1–P2 or P3–P2 pseudo-commissure was sutured if the P2 translation caused splitting (hydrodynamic test). In type 3, a total quadrangular resection of P2 was performed (Fig 1A); P1 or P3 (the most redundant one) was 90° translated on annulus with apex to P3-annulus or P1-annulus contralateral junction (Fig 1B); P1–P3 or P3–P1 was eventually translated with or without sliding (Fig 2A).
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Fig 2. (Left) P1–P3 or P3–P1 translated with or without sliding; (right) "fan-shaped transposition" of the secondary chordae in bileaflet prolapse.
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In seven bi-leaflet prolapses, a "fan-shaped transposition" of the secondary chordae was performed before proceeding to the Z-plasty suture (Fig 2B). Ring annuloplasty with glutaraldehide-fixed autologous pericardium was performed in all.
Intraoperative transesophageal echocardiography was always performed at the end of cardiopulmonary bypass by dedicated echocardiographists [2]. Echocardiography was performed using an Acuson Sequoia (Mountain View, CA). Measurements were obtained usung the guidelines of the American Society of Echocardiography. Two-dimensional measurements were taken from inner to inner edges. Anatomical measurements involved the inter-papillary muscles distance in diastole and systole, measured at the mid-papillary level from the parasternal short-axis view [3]. Ejection fraction was calculated by the Simpson’s method. Quantification of mitral valve area was made by pressure half method. Mean gradients were also calculated. The severity of mitral regurgitation was judged by an experienced cardiologist according to the extent and width of color–Doppler regurgitation jet, and was categorized as none (0), trace (0.5+), mild (+), moderate (2+), moderate to severe (3+), or severe (4+).
Anterior mitral leaflet mobility and posterior mitral leaflet mobility (PMLM) were graded as good, mild, and fixed.
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Comment
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There were no hospital deaths. Intraoperative echocardiography showed no residual significant regurgitation in all cases.
All patients were followed-up (2 years for 8 patients, 1 year for 7 patients, 6 months for 6 patients, and < 6 months for 4 patients); all of these patients were in New York Heart Association functional class I and were on sinus rhythm.
During the follow-up they underwent transthoracic echocardiography: inter-papillary muscles distance in diastole and inter-papillary muscles distance in systole were in the normal range, as were the ejection fraction and mitral valve area. Mitral regurgitation was absent in 14 patients and was trace in 11. In all patients there was a good motion of mitral leaflets as far as the PMLM was concerned in which 18 patients were good, 7 were mild, and 0 were fixed; there were no findings of left ventricle inflow tract obstruction in any of the patients, as well as systolic anterior motion of anterior leaflet was not found.
Compared with the traditional reconstructive techniques of posterior mitral leaflet (ie, linear reconstruction and sliding) the surgical results and the clinical and echocardiographic findings confirm the effectiveness of Z-plasty suture in degenerative mitral valve insufficiency with normal or not excessively dilated annulus, normal, or hypertrophic septum-posterior wall, normal inter-papillary muscles distance (Fig 3), and not dilated left ventricle.
In our opinion, the safety and effectiveness of the Z-plasty suture technique for complex reconstructions of posterior mitral leaflet was mainly demonstrated by the achievement of a satisfactory mitral valve area, with absent or trivial residual mitral regurgitation and good PMLM in most of the patients. Furthermore, we emphasize the excellent hemodynamic performance obtained through a normal inter-papillary muscles distance both in diastole and in systole, without any kind of left ventricle inflow tract obstruction.
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References
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- Lessana A, Carbone C, Romano M, et al. Mitral valve repair: results and the decision-making process in reconstruction J Thorac Cardiovasc Surg 1990;99:622.[Abstract]
- Matsunaga A, Shah PM, Raney Jr AA. Impact of intraoperative echocardiography/surgery team on succesful mitral valve repair: a community hospital experience J Heart Valve Dis 2005;3:325-330.
- Babburi H, Oommen R, Brofferio A, Ilercil A, Frater R, Shirani J. Functional anatomy of the normal mitral apparatus: a transthoracic, two-dimensional echocardiographic study J Heart Valve Dis 2003;12:180-185.[Medline]
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E. B. Savage
Z-Plasty: New or Folding-Plasty Redux
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R. Bellitti and P. Sante
Reply.
Ann. Thorac. Surg.,
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Abstract
Introduction
