Ann Thorac Surg 2001;71:379-380
© 2001 The Society of Thoracic Surgeons
Invited commentary: how to do it
Invited commentary
Mehmet Oz, MDa,
Christopher Mutrie, BAa
a Department of Cardiothoracic Surgery, Columbia-Presbyterian Medical Center, Milstein Hospital, Suite 7-435, 177 Fort Washington Ave, New York, NY 10032, USA
e-mail: mco2{at}Columbia.edu
This innovative approach to mitral regurgitation is especially valuable in technically challenging cases such as reoperations and fragile patients. We have used the technique successfully in 10 cases [1] without evidence of mitral stenosis and with one case of residual moderate regurgitation and one late mortality unrelated to the mitral valve. No patient has required reoperation, although mean follow-up for the cohort is under 2 years. Short follow-up is, in fact, the major concern with this technique, and we cannot be assured that these patients will not develop regurgitation over time; however, longer term follow-up in patients receiving a transatrial Alfieri suture has not identified an unexpectedly high incidence of recurrent regurgitation. The second most important concern is that mitral regurgitation naturally improves after repair of a dysfunctional aortic valve, so the impact of this procedure on the natural history of these patients remains unclear. With successful suture placement, mitral regurgitation is completely eliminated and perioperative management is facilitated, so we tend to choose this technique in higher risk patients.
Several technical concerns should be emphasized. We do not use plegetted sutures as advocated by the authors and are concerned that suture fracture could lead to embolization of this material. The suture must be placed centrally at a point best identified by pulling the leaflet taught and identifying the decussation point of chordae form the two papillary muscles on each leaflet. No paracommissural sutures are possible, so only central mitral regurgitation can be addressed. Finally, the suture is easiest to place in patients suffering aortic insufficiency with large aortic roots. Surgeons should become comfortable with this approach on these cases, even if a suture is not placed, in order to facilitate suture placement in patients with more challenging anatomy.
References
-
Kavarana M.N., Barbone A., Edwards N.M., Levinsson M.M., Oz M.C. Transaortic Repair of Mitral Regurgitation. The Heart Surgery Forum 2000;3:24-28.[Medline]
