Ann Thorac Surg 2009;87:324-325. doi:10.1016/j.athoracsur.2008.04.066
© 2009 The Society of Thoracic Surgeons
How To Do It
A Simple Method of Prevention for Systolic Anterior Motion in Mitral Valve Repair by Loop Technique Method
Mikihiko Kudo, MD, PhD*,
Ryohei Yozu, MD, PhD,
Kiyikazu Kokaji, MD, PhD,
Naritaka Kimura, MD
Department of Cardiovascular Surgery, Keio University School of Medicine, Keio University, Tokyo, Japan
Accepted for publication April 21, 2008.
* Address correspondence to Dr Kudo, Department of Surgery, School of Medicine, Keio University, 35 Shinano-machi, Shinjuku-ku, Tokyo, 160-8582, Japan (Email: m-kudo{at}sc.itc.keio.ac.jp).
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Abstract
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The loop technique is commonly adopted as a surgical procedure in mitral valve repair to secure the effective valve area of the valve leaflet, and to preserve, as much as possible, the physiological movement of the valve leaflet or annulus. On the other hand, the prolapsed valve leaflet is very high in some patients. In this case, the redundant valve leaflet may increase the risk of development of postoperative systolic anterior motion because the valve leaflet is not surgically removed at all. In this article, we describe a simple procedure for preventing systolic anterior motion after mitral valve repair using the loop technique.
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Introduction
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Chordal replacement with expanded polytetrafluoroethylene (ePTFE) CV-5 sutures for ruptured or elongated chordae tendineae of the mitral valve is becoming widespread with good long-term results [1, 2]. The difficult aspect of chordal replacement using expanded polytetrafluoroethylene sutures are that the knot easily slides when knotting expanded polytetrafluoroethylene sutures and determining the correct length of artificial chordae. To solve these problems, the loop technique [3] is commonly adopted as a surgical procedure in mitral valve repair to secure the effective valve area of the valve leaflet and to preserve, as much as possible, the physiological movement of the valve leaflet or annulus. On the other hand, the prolapsed valve leaflet is very high in some patients. In this case, the redundant valve leaflet may increase the risk of development of postoperative systolic anterior motion (SAM) because the valve leaflet is not removed surgically at all. In this article, we describe a simple procedure for preventing SAM in mitral valvuloplasty using the loop technique.
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Technique
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The loop is fixed to the prolapsed valve leaflet with another ePTFE CV-5 sutures to reconstruct the artificial chordae tendinae. A flexible or semi-rigid artificial ring is selected to preserve the flexibility of the valve annulus on the valvuloplasty side without downsizing. The artificial ring, sizes ranging from 32 mm to 38 mm, is selected. In this manner, broad-range mitral valvuloplasty is possible without removing the valve leaflet. After completion of mitral valve reconstruction, the height of the valve leaflet on the posterior leaflet side is measured. The height of the valve leaflet on the posterior leaflet side may measure 1.5 cm or more. In this case, the part concerned is additionally sutured to reduce its height (Fig 1). In practical treatment, a reduction suture of 4-0 polyester braid sutures with spaghetti is placed to reduce the height of the valve leaflet to 1.5 cm or less. Generally, the procedure is completed with two or three mattress sutures to the posterior leaflet (Fig 2). Addition of this procedure allows preservation of flexibility and physiological movement of the valve leaflet, and it rarely compromises the advantages of the loop technique.
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Fig 1. A measurement of height of posterior mitral leaflet is done after completion of the mitral valve reconstruction. This case was added to reduction suture because the height of posterior leaflet was more than 1.5 cm.
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Fig 2. A reduction suture of 4-0 polyester braid sutures with spaghetti is placed to reduce the height of the valve leaflet to 1.5 cm or less.
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Comment
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In mitral valve repair for mitral valve regurgitation, a leaflet excision and re-suture can cause partial degradation of leaflet mobility as a result of consolidation and cicatrization in the future. Ideally, physiological movement of the valve leaflet and the valve annulus should be preserved as much as possible. Therefore, we use mitral valve repair with the loop technique. This technique enables a physiological movement of the treated parts of the valve leaflet and annulus. Postoperative echocardiography shows good mobility of the valve leaflet on the repair side. We selected cases of posterior leaflet repair and compared the loop group (omission of posterior leaflet resection) and the nonloop group (implementation of posterior leaflet resection) with respect to diastolic transmitral valve pressure gradient. The results showed a significant difference (1.2 ± 0.6 mm Hg [loop group, n = 64] vs 3.3 ± 1.0 mm Hg [nonloop group, n = 110]; p = 0.001). These results also suggest hemodynamic usefulness [4].
The SAM caused by redundant valve leaflet occasionally becomes a problem; which was subsequently confirmed by measurement after completion of the mitral valve repair. This simple procedure requires only a reduction suture of the higher part of the valve leaflet, which is subsequently confirmed by measurement after completion of the mitral valve repair. Our procedure is an additional manipulation after the completion of mitral valve repair using the loop technique, and it was developed based on the known characteristics of the loop technique. The prevention of SAM by this simple method was performed for 20 patients. The repair side satisfactory flexibility of the long-term period is maintained (Fig 3). It contributes to the prevention of SAM. However, the height of the valve leaflet is extremely high in some patients, such those who have Barlow disease. In these cases, the surgical treatment cannot be accomplished using our procedure alone. To treat these cases, we use a combination of triangular resection and the loop technique for mitral valve repair.
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Fig 3. A 3-year postoperative echocardiogram reveals physiological movement of posterior leaflet, which our simple prevention method added to the (A) systolic phase and the (B) diastolic phase. (Arrows indicate posterior leaflet.)
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We described the maneuver and feasibility of technique for preventing SAM based on our experiments. This technique can be useful through both port-access minimally invasive cardiac surgery and conventional approaches to the mitral valve, which simplifies mitral valve repair with port-access minimally invasive cardiac surgery.
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References
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- Frater RWM. 10th Goretex chorda anniversary J Heart Valve Dis 1996;5:348-351.[Medline]
- David TE, Armmstrong S, Sun Z. Replacement of chordae tendineae with Gore-tex suture: a ten-year experience J Heart Valve Dis 1996;5:352-355.[Medline]
- Oppell UOV, 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]
- Kudo M, Yozu R, Kokaji K, Iwanaga S. Feasibility of mitral valve repair using the loop technique Ann Thorac Cardiovasc Surg 2007;13:21-26.[Medline]
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Abstract
Introduction
