The Puig-Massana-Shiley annuloplasty ring for mitral valve repair: experience in 126 patients

Mitral valve repair vs replacement. Current recommendations and long-term results

Techniques now exist to correct abnormalities of all components of the mitral valvular apparatus except extensive loss of pliable leaflet area. Thus, paradoxically, myxomatous valves with redundant leaflets represent the ideal candidates for mitral valve repair. Repair for mitral insufficiency can be performed for some rheumatic valves, but patient selection is critical. Loss of leaflet area, leaflet thickening, and extensive calcification of the leaflets or commissures are contraindications to repair. The abnormalities of the subvalvular apparatus are less important because a complete set of new chordae can be reconstructed using PTFE suture material. Some cases of endocarditis are ideal for repair using localized débridement and pericardial patch repair with or without PTFE chordal replacement. True ischemic mitral regurgitation of the Carpentier type I category is still something of a surgical enigma. Because it is a restrictive leaflet motion problem, annuloplasty alone is not always effective, and the outcome of any given repair attempt is less predictable. Repairs in patients with small annuli and multiple leaflet defects requiring complex series of maneuvers have a low probability of success. Furthermore, such patients with small left ventricular cavities are more prone to experience SAM. Several factors contributing to which therapy is chosen for mitral valve disease are summarized in Table 1. Patient selection, accurate evaluation of the cause or causes of mitral regurgitation, and well-executed application of the appropriate techniques for repair are all critical factors in the early and late success of mitral valve repair.

Circular Plication Annuloplasty for Rheumatic Mitral Valve Disease

Fourteen patients with mitral regurgitation and annular dilatation of rheumatic origin underwent surgery at İzmir State Hospital between May 1991 and January 1995. Number 2 polyester suture was attached around the posterior mitral annulus and circular plication was performed by tightening the suture to obtain a competent mitral valve with the largest possible nonstenotic orifice. Preoperatively all the patients had grade 3 or 4 (mean grade 3.41 ± 0.14) mitral regurgitation diagnosed by color Doppler echocardiography. At follow-up (mean follow-up time 35 ± 6.1 months), echocardiography showed 6 patients had grade 1 mitral regurgitation, 6 patients had grade 2, and 2 patients had no regurgitation (mean grade 1.28 ± 0.19). Postoperatively, the mean mitral valve area was found to be 2.74 ± 0.25 cm2 by pressure half-time echocardiography. The mean left ventricular diastolic diameter was 63 ± 2.9 mm preoperatively and 52 ± 1.7 mm postoperatively ( p < 0.05). The mean gradient across the mitral valve was 5.72 ± 0.78 mm Hg. Success (reduction of mitral regurgitation by at least 2 grades) was 86% at the end of the follow-up period. This annuloplasty technique was found to be a quick and effective method of reducing annular dilatation while maintaining annular flexibility.

Video-assisted mitral valve operations

BACKGROUND

Video-assisted endoscopy has been applied frequently in the management of a variety of surgical diseases. However, it has rarely been applied in mitral valve surgery.

METHODS

We report 2 patients who received emergency operations for thrombosis of a mitral prosthesis (patient 1, a 68-year-old man) and acute mitral regurgitation due to rupture of anterior chordae (patient 2, a 75-year-old woman). They both had severe congestive heart failure. Cardiogenic shock was noted in patient 2. The mitral valve was approached through a right anterior minithoracotomy with the aid of an endoscope by means of projected images on the video monitor under femorofemoral cardiopulmonary bypass. The aorta was not cross-clamped, and the myocardium was protected by continuous coronary perfusion with hypothermic fibrillatory arrest. The left atrium was entered posterior to the interatrial groove. Thrombectomy and mitral valve repair were performed successfully.

RESULTS

The duration of extracorporeal circulation was 204 and 147 minutes, respectively. Both patients recovered from the operation rapidly with uneventful postoperative courses.

CONCLUSIONS

Our preliminary results suggest that video-assisted endoscopic cardiac surgery is technically feasible and could be performed in the milieu of open heart surgery.

Mitral valve remodeling: long-term results with posterior pericardial annuloplasty

BACKGROUND

We studied the long-term results of a technique of mitral annuloplasty using autologous pericardium.

METHODS

Between June 1989 and December 1994, 113 mitral valvuloplasties were performed for myxomatous degenerative disease. Repair of isolated anterior leaflet prolapse was performed in 26 patients (23%), posterior leaflet prolapse in 38 (33.6%), and prolapse of both leaflets in 49 (43.4%). Posterior pericardial annuloplasty was performed in all patients. In 20 patients, the pericardial graft was marked with metal clips for postoperative cinefluoroscopic assessment of annulus motion.

RESULTS

The operative mortality rate was 2.7% (3/113). One patient died of myocardial infarction and 2 of low cardiac output syndrome. One patient required replacement of the mitral valve 2 days after operation because of dehiscence of the annular plication. Follow-up (average length, 32.41 +/- 20.09 months; range 1 to 71 months) was 97% complete and revealed good clinical and functional results: 95 patients (84.1%) were in New York Heart Association class I and had no regurgitation or only mild residual regurgitation. Postoperative transmitral flow indices were almost normal (mitral valve area = 3.7 +/- 0.4 cm2; peak flow velocity = 1.06 +/- 0.2 m/s). Only 3 patients had reoperation within 3 years (actuarial 5-year reoperation-free rate, 89.7%) and event-free survival at 5 years was 91%. In patients with metal clips marking autologous pericardium, planimetry of the area derived by fluoroscopic examination showed systolic narrowing of annulus size (8.5% +/- 6.4%; p < 0.01) and a slight systolic fall in the anteroposterior diameter of the annulus contour (5.9% +/- 3.8%; p < 0.01).

CONCLUSIONS

Posterior pericardial annuloplasty seems to be a safe, effective and easily performed technique and a more physiologic correction that preserves mitral annulus motion.

Long-term results of polytetrafluoroethylene mitral annuloplasty

Prosthetic rings are customarily used for mitral annuloplasty to plicate and reinforce the annulus and keep the annulus from further dilating. From July 1984 to March 1992, mitral annular plication using polytetrafluoroethylene (PTFE) graft material was performed on 73 patients (age range, 15 to 69 years; mean, 35.7 years) with mitral regurgitation. The cause of the mitral regurgitation was rheumatic in 50.7% and degenerative in 36.9% of the patients. After other repair procedures on the mitral valve apparatus had been performed, a PTFE graft (3 mm) was tailored to the length of the free edge of the anterior leaflet and then inserted at the posterior part of the mitral annulus between the commissures. The operative mortality was 2.7%. Follow-up ranged from 0.7 to 8.5 years (mean, 5.6 years). Postoperative echocardiography confirmed that 94.2% of the survivors had either no or only mild mitral regurgitation with a large mitral valve area (2.7 +/- 0.3 cm2) and almost no pressure gradient across the mitral valve or left ventricular outflow tract. Two patients successfully underwent redo PTFE mitral annuloplasty. Two patients died, one 15 and the other 20 months later, due to myocardial failure, with no mitral regurgitation. The event-free survival rate was 90% +/- 4% at 8 years. We conclude that PTFE mitral annuloplasty is an effective procedure that yields good long-term results.

Mitral valve repair using a flexible and adjustable annuloplasty ring

Initial experience with a new flexible and adjustable mitral annuloplasty ring is described. Used in conjunction with standard techniques of mitral valve repair, this ring was implanted in 21 consecutive patients undergoing elective operation for mitral regurgitation. Satisfactory valve repair was feasible in 20 of these patients. Once the ring was sewn in place, adjustment of the ring to reduce or eliminate residual regurgitation was beneficial in 9 patients. Excellent results were achieved as determined by intraoperative transesophageal echocardiography. Comparable late results were found in all but 1 patient up to 1 year after repair. This patient required mitral valve replacement 6 months after repair due to failure of papillary muscle reconstruction. The BiFlex ring has the merits of a flexible prosthesis with the advantage of easy adjustment once secured in place.

Comparative morbidity of mitral valve repair versus replacement for mitral regurgitation with and without coronary artery disease

Mitral valve repair has been increasingly used at our hospital for mitral regurgitation with and without coronary disease. From January, 1984, to June, 1987, of 338 patients undergoing all forms of mitral valve surgery, 140 had first-time surgery for pure mitral regurgitation: 75 had valve repair, and 65 had valve replacement. Thirty-three of 75 (44%) had concomitant coronary bypass in the repair group, while 21 of 65 (32%) had coronary bypass in the replacement group. The mean functional class (3.4 versus 3.5), age (60 versus 61 years), and preoperative hemodynamics were similar in both groups. The cause of mitral regurgitation in the repair group was myxomatous change in 32 patients, ischemia in 27, rheumatic valve disease in 12, and endocarditis in 4. A Carpentier ring was used in 46, a Duran ring was used in 11, and none was used in 18. The operative mortality was 3 of 75 patients (4%) in the repair group, all with coronary artery bypass grafting, versus 2 of 65 patients (3%) in the replacement group, 1 of whom had undergone coronary artery bypass grafting. The mean postoperative functional class 15 months postoperatively was 1.12 in the repair group versus 1.15 in the replacement group. There were 7 late deaths in the replacement group and only 3 late deaths in the repair group. Actuarial survival at 30 months was 85 +/- 6% for the replacement group and 94 +/- 4% for the repair group. There were 5 late emboli (1 fatal, 4 nonfatal) after valve replacement and none after valve repair (p = 0.03).(ABSTRACT TRUNCATED AT 250 WORDS)