ATS
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

Ann Thorac Surg 2008;86:1388-1390. doi:10.1016/j.athoracsur.2008.04.010
© 2008 The Society of Thoracic Surgeons
This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Minoru Tabata
Prem S. Shekar
Lawrence H. Cohn
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Tabata, M.
Right arrow Articles by Cohn, L. H.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Tabata, M.
Right arrow Articles by Cohn, L. H.
Related Collections
Right arrow Valve disease

How To Do It

Early and Midterm Outcomes of Folding Valvuloplasty Without Leaflet Resection for Myxomatous Mitral Valve Disease

Minoru Tabata, MD, MPH, Ravi K. Ghanta, MD, Prem S. Shekar, MD, Lawrence H. Cohn, MD*

Division of Cardiac Surgery, Brigham and Women's Hospital, Boston, Massachusetts

Accepted for publication April 2, 2008.

* Address correspondence to Dr Cohn, Division of Cardiac Surgery, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02446 (Email: lcohn{at}partners.org).


   Abstract
Top
 Abstract
Introduction
 Technique
 Comment
 References
 
We performed 46 cases of folding valvuloplasty without leaflet resection for myxomatous mitral regurgitation (MR) between August 2004 and December 2006. Operative mortality was zero. No patient had greater than grade 1 MR or systolic anterior motion on intraoperative transesophageal echocardiography. In median of 17 months' follow-up, no patient had a reoperation for recurrent MR. Among 31 patients who had an echocardiographic follow-up, 28 had zero or grade 1 MR, 3 had grade 2 MR, and no patient had grade 3/4 MR. Folding valvuloplasty is a simple and effective technique for selected types of myxomatous MR with favorable outcomes and midterm echocardiographic findings.


   Introduction
Top
 Abstract
 Introduction
Technique
 Comment
 References
 
Quadrangular resection and sliding valvuloplasty is the classic standard technique for posterior leaflet prolapse of myxomatous mitral valve disease [1] and sliding valvuloplasty. Several simpler techniques without leaflet resection have been introduced. Before introduction of quadrangular resection, McGoon [2] developed the leaflet plication technique that can be applied to the anterior and posterior leaflet. Recently, Calafiore and colleagues [3] and Mihaljevic and colleagues [4] described a folding leaflet technique without leaflet resection that effectively reduces the height of the redundant posterior leaflet; however, the number of reported cases is limited and the postoperative echocardiographic outcomes are unknown.

We report our experience of folding valvuloplasty without leaflet resection for myxomatous mitral valve disease of the posterior leaflet. The aim of this study is to assess effectiveness and midterm durability of this technique.


   Technique
Top
 Abstract
 Introduction
 Technique
Comment
 References
 
This study was approved by the institutional review board of Brigham and Women's Hospital (protocol number: 2006p002403), a waiver of informed consent was obtained for data collection from medical records, and written informed consents were obtained from patients for midterm outcomes data collection.

We conducted a retrospective review of 46 consecutive patients who underwent folding valvuloplasty without leaflet resection for myxomatous mitral regurgitation (MR) disease between August 2004 and December 2006 at Brigham and Women's Hospital.

We collected perioperative data from the patient medical records and Brigham and Women's Hospital Cardiac Surgery Database according to the Society of Thoracic Surgery National Adult Cardiac Database, version 2.52. We investigated reoperation histories and cardiac symptoms through a questionnaire or telephone interview. In addition, we contacted their primary care physicians or cardiologists to collect midterm echocardiographic results. If an echocardiographic report showed only qualitative MR grade, we translated it to quantitative one, described by the American Society of Echocardiography as "mild" to grade 1, "moderate" to grade 2, "moderate to severe" to grade 3, and "severe" to grade 4.

Intraoperative transesophageal echocardiography was used in all cases. Procedures were performed through a lower hemisternotomy (n = 26) or full sternotomy (n = 20). The mitral valve was approached through the interatrial groove incision and left atrium and carefully inspected. After indentifying prolapsed area, we put 1 to 6 double armed 4-0 polypropylene sutures from the leaflet edge to the annulus on the prolapsed or redundant portion of the posterior leaflet. We then tied sutures, thus folding over the leaflet to reduce the height of the leaflet (Fig 1). The height of the leaflet can be adjusted by changing the entry or exit points of sutures. The number of sutures depends on the width of the prolapsed or redundant portion. A flexible annuloplasty ring was placed with 2-0 braided polyester mattress sutures in all patients. The ring size was selected based on the surface area of anterior leaflet. Leak tests were performed to make sure that the valve was adequately repaired. An edge-to-edge suture was added for systolic anterior motion (SAM) prophylaxis in 7 patients who were prospectively evaluated. The valve was evaluated with transesophageal echocardiography after bypass.


Figure 1
View larger version (37K):
[in this window]
[in a new window]

  		Fig 1. (A) A double-armed suture is placed from the tip of prolapsed leaflet to the annulus. (B) A suture is tied to fold the leaflet down.

 
Median age was 63 years (range, 35 to 84 years) and 24 patients (52%) were women. Other patient characteristics are shown in Table 1.


View this table:
[in this window]
[in a new window]

  		Table 1 Preoperative Characteristics of All the Patients
 
The folded portions were P2 (n = 21); P2 and P3 (n = 8); P1, P2, and P3 (n = 8); P1 and P2 (n = 3); P1 (n = 3); and P3 (n = 3). Thirty-four patients had isolated mitral valve repair and 12 patients had concomitant cardiac procedures. Median cardiopulmonary bypass and aortic cross-clamp times were 105 and 75 minutes, respectively. No patient was found to have greater than grade 1 residual MR or systolic anterior motion after repair by intraoperative transesophageal echocardiography. The operative mortality rate was zero and median length of stay was 6 days.

Follow-up was obtained on 93% of patients (43 of 46 patients) with a median follow-up time of 17 months (range, 3 to 29 months). No patient had a reoperation for recurrent MR. All patients were New York Heart Association functional class I or II. Thirty-one patients had a postoperative echocardiogram more than 3 months after surgery (median follow-up, 12 months; range, 3 to 23 months). Twenty-eight patients had zero and grade 1 MR, and 3 patients had grade 2 MR. Three patients who were found to have grade 2 MR had been asymptomatic since surgery.


   Comment
Top
 Abstract
 Introduction
 Technique
 Comment
References
 
We present early and midterm outcomes of 46 cases of posterior leaflet folding valvuloplasty without leaflet resection in patients without ruptured chords or flail leaflet. This technique fixes leaflet prolapse and reduces posterior leaflet height. The advantages of folding valvuloplasty include technical simplicity and broad applicability. Folding valvuloplasty can be used in any segment of posterior leaflet. We use this technique for posterior leaflet prolapse without ruptured chords. Folding valvuloplasty with multiple folding sutures simply fixes prolapse of extensively long valve segment, whereas quadrangular resection requires sliding valvuloplasty [4].

In addition, this technique allows a surgeon to undo and readjust the height of leaflet or try another technique. In a few cases, we found poor coaptation because of overly shortened posterior leaflet and fixed it by undoing some of the folding sutures after ring placement.

Although we only included folding valvuloplasty without leaflet resection in this series, this technique can be combined with leaflet resection, when P1 or P3 is found to be still high after quadrangular resection and approximation of the remnant leaflet.

An annuloplasty ring is always placed with this technique, because it has been shown to improve durability of valve repair of myxomatous mitral valve by remodeling [5, 6]. In addition, because folding valvuloplasty without leaflet resection is conceptually equivalent to uni-cuspidization of the mitral valve, adjusting the annulus size to the anterior leaflet size is essential to obtain adequate coaptation. Mihaljevic and colleagues [4] used the folding sutures to anchor the annuloplasty ring. It may save time and resources; however, we prefer to use separate sutures because it may be necessary to undo a suture after ring placement due to extensive shortening and our technique allows that without compromising ring fixation.

An edge-to-edge suture is a useful concomitant technique. We assessed the anterior leaflet after folding valvuloplasty and ring annuloplasty, and added an edge-to-edge suture in 7 patients for systolic anterior motion prophylaxis [7]. We use an edge-to-edge suture for this indication combined with the classic leaflet resection technique, as well in patients in who had pre-repair transesophageal echocardiography show a high probability of postoperative systolic anterior motion.

Limitation of this study is the observational nature without a comparative control and limited number of cases. Also, longer-term durability is unknown, and further investigation is necessary.

In conclusion, folding valvuloplasty without leaflet resection is a simple effective technique for repairing myxomatous MR of the posterior leaflet with favorable early and midterm outcomes.


   References
Top
 Abstract
 Introduction
 Technique
 Comment
 References
 

  1. Carpentier A, Relland J, Deloche A, et al. Conservative management of the prolapased mitral valve J Thorac Cardiovasc Surg 1978;26:294-302.
  2. McGoon DC. Repair of mitral insufficiency due to ruptured chordae tendineae J Thorac Cardiovasc Surg 1960;39:357-362.
  3. Calafiore AM, Di Mauro M, Actis-Dato G, et al. Longitudinal plication of the posterior leaflet in myxomatous disease of the mitral valve Ann Thorac Surg 2006;81:1909-1910.[Abstract/Free Full Text]
  4. 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]
  5. Cohn LH, Couper GS, Aranki SF, Rizzo RJ, Kinchla NM, Collins Jr JJ. Long-term results of mitral valve reconstruction for regurgitation of the myxomatous mitral valve J Thorac Cardiovasc Surg 1994;107:143-150.[Abstract/Free Full Text]
  6. 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]
  7. Brinster DR, Unic D, D'Ambra MN, Nathan N, Cohn LH. Midterm results of the edge-to-edge technique for complex mitral valve repair Ann Thorac Surg 2006;81:612-617.



This article has been cited by other articles:


Home page
 J. Thorac. Cardiovasc. Surg.Home page
M. Padala, S. N. Powell, L. R. Croft, V. H. Thourani, A. P. Yoganathan, and D. H. Adams
Mitral valve hemodynamics after repair of acute posterior leaflet prolapse: quadrangular resection versus triangular resection versus neochordoplasty.
J. Thorac. Cardiovasc. Surg., August 1, 2009; 138(2): 309 - 315.
[Abstract] [Full Text] [PDF]

This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Minoru Tabata
Prem S. Shekar
Lawrence H. Cohn
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Tabata, M.
Right arrow Articles by Cohn, L. H.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Tabata, M.
Right arrow Articles by Cohn, L. H.
Related Collections
Right arrow Valve disease

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
ANN THORAC SURG ASIAN CARDIOVASC THORAC ANN EUR J CARDIOTHORAC SURG
J THORAC CARDIOVASC SURG ICVTS ALL CTSNet JOURNALS