Risk factors of posterior pericardial annuloplasty for isolated posterior leaflet prolapse

Clinical and pathological features of degenerative mitral valve disease: billowing mitral leaflet versus fibroelastic deficiency

PURPOSE

Degenerative mitral valve disease is distinguished with billowing mitral leaflet (BML) or fibroelastic deficiency (FED). The purpose of this study is to evaluate the clinical characteristics and the pathohistological differences between BML and FED.

METHODS

A total of 73 patients who diagnosed as degenerative mitral valve disease pathologically after mitral valve surgery for severe mitral regurgitation were enrolled. On the basis of echocardiographic features and gross appearances, they were classified as BML (9 cases) and FED (64 cases).

RESULTS

In the BML group, multiple segments of the leaflet showed billowing with elongated chordae. Therefore excessive valve tissue needed to be removed by multiple resection and suture. The FED patients had focal myxomatous changes with ruptured chordae, a single resection and suture was frequently employed. In pathological examination, the valve thickness of the BML was nearly twice as thick as the FED, and the mucopolysaccharide accumulation of the Spongiosa in the BML was over 50%, while 30% in the FED.

CONCLUSION

BML presents the characteristic valve thickening due to its abnormal production of mucopolysaccharide. Since excessive tissue was voluminous in the BML, high-grade plasty techniques, such as combination of multiple resection and chordal reconstruction were required.

Time-dependent change in fresh autologous pericardium applied for posterior mitral annuloplasty: degree of calcification and its influence on the repaired mitral valve

OBJECTIVE

To investigate the degree of calcification of fresh autologous pericardium applied for posterior mitral annuloplasty and its influence on the repaired mitral valve.

METHODS

Thirty-nine patients (31 degenerative and 8 infective endocarditis; mean age at surgery: 62 ± 11 years) were enrolled in this study. Sixteen-slice multi-detector computed tomography was performed to identify calcification of autologous pericardium. The mean clinical follow-up was 4.6 ± 2.6 years (maximum 8.8 years) and the mean computed tomography follow-up period was 3.6 ± 2.5 years (maximum 7.6 years) after surgery.

RESULTS

Pericardial calcification was detected in 15 patients. The earliest detection of calcification was 2.5 years after surgery. There was a weak correlation between pericardial calcification and postoperative years (Pearson's product correlation coefficient: 0.476; p = 0.0019). However, severe calcification of autologous pericardium did not occur in any case. There was no association between pericardial calcification and recurrent mitral regurgitation (p = 0.1145). The mean mitral valve orifice area and the mean transmitral pressure gradient in the 15 patients with calcification were 3.0 ± 0.6 cm(2) and 2.1 ± 1.0 mmHg, respectively.

CONCLUSIONS

Calcification of the fresh autologous pericardium increased with postoperative years. It had no adverse effects on repaired mitral valve in the short-term follow-up period. We will report the findings once again when the follow-up reaches 10 years.

Posterior pericardial annuloplasty in ischemic mitral regurgitation

BACKGROUND

Ischemic mitral regurgitation (IMR) is an important risk factor in coronary artery bypass grafting (CABG) operations. The decision to perform concomitant mitral annuloplasty along with the CABG depends on the surgeon's choice. The aim of this study was to evaluate the results of posterior annuloplasty procedures with autologous pericardium performed in patients with midadvanced and advanced functional ischemic mitral regurgitation.

METHODS

Study participants were 36 patients with IMR (mean age 59 +/- 10 years) who underwent posterior pericardial annuloplasty and CABG operations between 2002 and 2007. Preoperative and postoperative (mean follow-up 18 +/- 1 months) MR grade, left atrium diameter, left ventricle end systolic diameter, left ventricle end diastolic diameter, left ventricle ejection fraction, and mitral valve gradients were measured with transthoracic echocardiography.

RESULTS

There was one late mortality (2, 8%) but none of the patients required reoperation for residual MR. We did not observe thromboembolism, bleeding, or infective endocarditis. The mean MR grade decreased from 3.4 +/- 0.5 to 0.5 +/- 0.6 (P < .01), left atrium diameter decreased from 45.3 +/- 5.5 mm to 43.2 +/- 3.8 mm (P < .01), left ventricle end diastolic diameter decreased from 53.2 +/- 5.6 mm to 50.9 +/- 5.5 mm (P < .01), and left ventricle end systolic diameter decreased from 39.7 +/- 5.8 mm to 34.6 +/- 6.5 mm (P < .01), whereas mean left ventricle ejection fraction increased from 37.9% +/- 6.1% to 43.7% +/- 7.3% (P < .01). In the late postoperative term, the functional capacity of the patients increased from mean New York Heart Association class 2.6 +/- 0.9 to 1.1 +/- 0.5. We did not observe any gradient in the mitral valve preoperatively in any patient, but in the follow-up, the mean gradient increased to 1.3 +/- 2.1 mmHg (P < .01).

CONCLUSION

Posterior pericardial annuloplasty with CABG in the treatment of IMR provides efficient mitral repair and significant decrease in the left atrium and left ventricle diameters, and provides a significant increase in left ventricular function. These results show IMR to be as effective as the other annuloplasty techniques. IMR is performed with autologous material and therefore does not entail any risk of complications from prosthetic material and is highly cost-effective.