Ann Thorac Surg 2008;85:1460-1462. doi:10.1016/j.athoracsur.2007.10.040
© 2008 The Society of Thoracic Surgeons
How To Do It
Robotic "Haircut" Mitral Valve Repair: Posterior Leaflet-Plasty
Michael W.A. Chu, MD,
Karen A. Gersch, MD,
Evelio Rodriguez, MD,
L. Wiley Nifong, MD,
W. Randolph Chitwood, Jr, MD*
East Carolina Heart Institute, Division of Cardiothoracic and Vascular Surgery, Brody School of Medicine, East Carolina University, Greenville, North Carolina
Accepted for publication October 9, 2007.
* Address correspondence to Dr Chitwood, East Carolina Heart Institute, Division of Cardiothoracic and Vascular Surgery, Brody School of Medicine, East Carolina University, 600 Moye Blvd, Greenville, NC 27858 (Email: chitwoodw{at}ecu.edu).
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Abstract
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Posterior leaflet prolapse has been repaired traditionally by leaflet resection with or without a sliding annuloplasty. However, substantial annular calcification, thin leaflets, or deficient P1 or P3 scallops can complicate this technique. Annular closure after large posterior leaflet resection introduces substantial radial stress even in the presence of a sliding annuloplasty. We describe a novel technique that corrects posterior leaflet prolapse, minimizes leaflet resection, and preserves posterior leaflet–annulus continuity. This reconstructive technique can be applied in traditional mitral valve repairs but is suited particularly to the robotic approach, in which enhanced visualization and dexterity make the "haircut" repair easy to perform.
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Introduction
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Mitral valve (MV) repair remains the gold standard for treating severe mitral regurgitation (MR) from myxomatous degeneration [1]. Traditionally, posterior leaflet resection, with or without a sliding annuloplasty, has been the primary treatment in severe valvular insufficiency secondary to posterior leaflet prolapse [1-3]. However, this technique becomes complicated in the presence of a large P2 scallop with multiple ruptured or redundant chords and either significant annular calcification, thin leaflets, or deficient P1 or P3 scallops that are too small to slide successfully. In addition, standard techniques usually render the posterior leaflet immobile, leaving the MV with one functional leaflet. Advances in robotic technology, including three-dimensional visualization and improved dexterity with enhanced operative precision, have facilitated the development of new repair techniques for MR.
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Technique
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We describe a novel repair technique that averts interruption of posterior leaflet–annulus continuity while conserving maximal leaflet tissue. From March 2006 to March 2007, 17 patients (mean age, 59.2 ± 9.9 years; 14 men) with severe MR secondary to isolated posterior leaflet prolapse underwent robotic "haircut" MV repair. Two patients had New York Heart Association class III or IV symptoms and 11 patients had a history of congestive heart failure. Other comorbidities included hypertension in 7 patients, smoking in 3 patients, and coronary artery disease in 3 patients.
Our standard minimally invasive robotic approach was used in all patients [4]. Endoscopic camera and surgical assistant access were established through a lateral 3-cm intercostal space incision. Peripheral cardiopulmonary perfusion, transthoracic aortic cross-clamping, and antegrade cardioplegia were used in every case. The four-arm da Vinci S Surgical System (Intuitive Surgical Inc, Sunnyvale, CA) was used for all portions of each repair, including leaflet resections and reconstructions, and chord manipulations and suture knot tying. The inset in Figure 1
suggests why we call this procedure the mitral "haircut" repair. The limits of the prolapsing P2 segment with associated ruptured or redundant chords are identified (Fig 1) and the height (annulus to tip) of each scallop is measured. Lateral P2 scallop edges are imbricated concomitant with P1-P2 and P2-P3 cleft closure (4-0 Cardionyl; Péters, Surgical, Bobigny, France). Incomplete natural clefts can be incised to facilitate imbrication. Completion of this part of the repair generally reduces the P2 segment prolapse substantially. Thereafter, excess P2 segment height is resected to the measured height of adjacent P1 and P3 scallops (Fig 2), with the goal of posterior leaflet height less than 15 mm. With this maneuver ruptured chords get a "haircut" with this resection. Redundant chords are preserved along with a tiny piece of leaflet-anchoring tissue and are reattached to the free edge of the P2 chord, restoring a sealed line of coaptation (Fig 3A). If all the P2 chords require resection, adjacent secondary chords can be transferred from either the posterior or anterior leaflet. Alternately, polytetrafluoroethylene neochords can be substituted. The repair is completed with an annuloplasty band (Cosgrove-Edwards; Edwards Lifesciences, Irvine, CA) (Fig 3B) and 2-0 Cardioflon sutures (Péters Surgical), which have excellent handling characteristics and require only four suture knots, facilitating a more expedient repair. Valve competence was assessed with the saline test combined with antegrade administration of cardioplegia.
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Fig 1. Typical flail P2 segment with adjacent short and thin P1 and P3 scallops. Inset suggests why we describe this as a "haircut" operation.
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Fig 3. (A) Preserved posterior leaflet chords can be reattached to free edge of P2 segment to pull the leaflet edge down into the ventricle and provide leaflet support. If adequate chords cannot be saved, secondary chords can be transferred from either the posterior or anterior leaflet. Posterior leaflet clefts are plicated. (B) Repair is completed with band annuloplasty.
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In this series, all "haircut" repairs included at least two chord transfers. All patients were repaired with a partial, flexible annuloplasty band (median dimension, 32 mm; range, 30-38 mm). Mean cardiopulmonary bypass and cross-clamp times were 155 ± 22 and 122 ± 16 minutes, respectively. All patients recovered uneventfully, with no mortalities, myocardial infarctions, or strokes. The median hospital length of stay was 4 days. Postoperative transesophageal echocardiograms demonstrated no MR in 16 patients and mild MR in 1 patient. Each echocardiogram showed mobility of both the posterior and anterior leaflets. There were no late complications.
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Comment
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In MV repair surgery, there is an increasing trend to preserve the mitral annulus and leaflet tissue [5, 6]. Recently, Gazoni and colleagues [7] reported a conservative approach to leaflet resection. The robotic "haircut" repair technique respects the anatomy of the MV and preserves physiologic mobility of the posterior leaflet. By maintaining annulus integrity and transferring or reattaching P2 chords, the posterior leaflet remains flexible and supported naturally. Moreover, this technique is particularly valuable when substantial annular calcification would complicate annular compression and reconstruction. A large flail P2 scallop is often associated with short or thin P1 and P3 scallops, which makes a traditional P1 or P2 sliding annuloplasty challenging to perform without leaflet tearing. Finally, the "haircut" repair reduces the chance of developing anterior MV leaflet systolic anterior motion by combining chord readjustments and P2 height reduction to less than 1.5 cm. Two potential concerns with this technique are dehiscence of the transferred chords and recurrent annulus dilatation. Although this series is early in follow-up, we have noted no problems with chord transfers performed earlier in our larger robotic MV repair series. In addition, we believe that restoration of the coaptation line and placement of an annuloplasty band provides sufficient support to redistribute the stress across all of the subvalvular apparatus. With regards to annulur dilatation, a complete ring may mitigate this late complication; however, we have yet to identify a flexible, complete ring that we believe is suitable for robotic techniques.
High-definition three-dimensional vision and superior robotic dexterity enables accurate "haircut" leaflet resections and precise chord transfers. To avert leaflet resections while reestablishing leaflet coaptation, von Oppell and Mohr [8] insert premeasured polytetrafluoroethylene neochord loops at various levels along the flail or redundant scallop. Others have advocated using folding valvuloplasties and posterior leaflet wedge resections with chord transfers to preserve leaflet-annulus integrity [5, 6]. The "haircut" technique provides an architecturally stable MV repair that is easier to perform robotically compared with traditional resections with sliding annuloplasties. Long-term follow-up is necessary to assess the durability of this repair technique.
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References
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- Braunberger E, Deloche A, Berrebi A, et al. Very long-term results (more than 20 years) of valve repair with Carpentier’s techniques in nonrheumatic mitral valve insufficiency Circulation 2001;104(12 suppl 1):8-11.
- 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]
- Mohty D, Orszulak TA, Schaff HV, Avierinos JF, Tajik JA, Enriquez-Sarano M. Very long-term survival and durability of mitral valve repair for mitral valve prolapse Circulation 2001;104(12 suppl 1):I1-I7.[Medline]
- Kypson AP, Nifong LW, Chitwood Jr WR. Mitral valve repair: robotic minimally invasiveIn: Kaiser LR, Kron IL, Spray TL, editors. Mastery of Cardiothoracic Surgery. Philadelphia, PA: Lippincott Williams & Wilkins; 1998. pp. 353-368.
- Dreyfus GD, Corbi P, Rubin S, Aubert S. Posterior leaflet preservation in mitral valve prolapse: a new approach to mitral repair J Heart Valve Dis 2006;15:528-530.[Medline]
- Mihaljevic T, Blackstone EH, Lytle BW. Folding valvuloplasty without leaflet resection: simplified method for mitral valve repair Ann Thorac Surg 2006;82:e46-e48.[Abstract/Free Full Text]
- Gazoni LM, Fedoruk LM, Kern JA, et al. A simplified approach to degenerative disease: triangular resections of the mitral valve Ann Thorac Surg 2007;83:1658-1665.[Abstract/Free Full Text]
- von Oppell UO, Mohr FW. Chordal replacement for both minimally invasive and conventional mitral valve surgery using premeasured Gore-Tex loops Ann Thorac Surg 2000;70:2166-2168.[Abstract/Free Full Text]
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Abstract
Introduction
