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Ann Thorac Surg 2007;84:1043-1044
© 2007 The Society of Thoracic Surgeons
a Assistance Publique-Hôpitaux de Paris, Service de Chirurgie Cardiovasculaire, Hôpital Européen Georges Pompidou, Paris, France
b Université René Descartes, Paris, France
Accepted for publication December 29, 2006.
* Address correspondence to Dr Zegdi, Hôpital Européen Georges Pompidou, Service de Chirurgie Cardiovasculaire, 20, rue Leblanc, Paris 75908, France (Email: rzegdi{at}hotmail.com).
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Abstract |
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Introduction |
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The mainstay of the surgical repair technique relies on posterior leaflet extension using an autologous pericardial patch [1]. Several technical hints resulting from more than 30 years of experience in our department are presented.
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Technique |
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The mitral valve is carefully inspected and the mechanisms of mitral regurgitation identified as previously reported [2]. Commissural fusioning should also be looked for. The decision to repair the mitral valve relies on the evaluation of the anterior leaflet pliability, depending on the extent of leaflet fibrosis or calcification. If leaflet fibrosis or calcification is extensive, then repair is likely to fail or to end up with significant mitral stenosis. A simple and effective technique to rapidly evaluate this is by pushing with a forceps the anterior mitral valve toward the left ventricle. If the anterior leaflet returns directly into position with a "reboundlike" effect, then fibrosis is too extensive. If it stays easily in place, then leaflet pliability is generally sufficient to perform repair, and we should move on to the next step.
Commissurotomy, when necessary, is first performed. Retraction of the posterior leaflet is usually very marked, and its height often reduced to no more than a few millimeters. The posterior leaflet is detached along the annulus. This incision should be extended as far as possible toward both commissures. Then the subvalvular apparatus is examined, and retracted secondary chordae should be excised. That would confer more mobility to the free margin of the extended leaflet.
An autologuous pericardial patch that has previously been pretreated with a 0.625% glutaraldehyde-buffered solution should then be tailored. The glutaraldehyde solution makes the pericardium stiffer, rendering it easier to handle. The length of the oval patch should correspond to the intercommissural distance (Fig 1). One should not hesitate to keep a height of at least 3 cm when tailoring the patch. After the loss of tissue due to the suture lines, there should remain enough tissue in place to allow the pericardium to bulge and move anteriorly during systole toward the anterior leaflet (Fig 2). The bulk of the pericardium would form the body of the posterior valve that would serve as an "abutment" to which the anterior leaflet would coapt during systole. The extremities of the patch should also be cut round and not sharp, to confer a greater height in the commissural region.
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The final step is inserting a prosthetic mitral annulus. The sizing is critical. According to Carpentier’s techniques, the choice of the ring relies on the measurement of the surface of the anterior leaflet [2]. In cases of rheumatic mitral regurgitation, however, an important pericardial extension of the posterior leaflet allows an oversizing (usually one size) of the prosthetic ring [1]. This oversizing has also the potential to prevent significant residual mitral stenosis, particularly when the anterior leaflet is small and mildly fibrotic.
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Comment |
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Mitral valve repair in rheumatic valve disease has been shown to give suboptimal but satisfying long-term results, with 82% freedom from reoperation at 10 years, and a considerably lower rate of thromboembolic events when compared with prosthetic mitral valve replacement [3]. That is particularly important in children and in women of child-bearing age.
Following these surgical rules, satisfying long-term results have been achieved (2% reoperation per year) in our department. A large posterior leaflet extension is critical in achieving these good results. We have never seen any systolic anterior motion of the anterior leaflet after repair of a rheumatic mitral insufficiency. That is explained by the fact that the anterior leaflet is usually short, with a pliability that is less than normal. Oversizing of the prosthetic ring also helps preventing systolic anterior motion.
Pericardial extension of the anterior leaflet provides better results than prosthetic annuloplasty alone in rheumatic mitral regurgitation [4]. However, there is still a controversy regarding the type (anterior or posterior) of the pericardial extension to perform. Although both techniques are easy to do, very long term satisfying results (20 years) have only been reported with the posterior pericardial extension [3]. Cuspal thinning is another way of extending the posterior leaflet. Although others have reported good long-term results [5], we abandoned it a long time ago as the technique is more challenging, and the resulting leaflet extension is usually modest.
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