Mitral annuloplasty with a suture technique

A good surgical option for ischemic mitral regurgitation in co-morbid patients: semicircular reduction annuloplasty

BACKGROUND

Ring annuloplasty is the standard treatment of ischemic mitral regurgitation (MR), however, it has been associated with some drawbacks. It abolishes normal annular dynamics and freezes the posterior leaflet. In the present study, we evaluated Paneth suture annuloplasty in chronic ischemic MR and both early and mid-term outcomes of the technique on a selected population.

METHODS

The study period was from June 2010 to June 2012. We operated on 21 patients who had the diagnosis of coronary artery disease and MR of grade 3 or 4. The patients had both a coronary artery bypass operation and the mitral semicircular reduction annuloplasty described by Paneth-Burr. The data on the patients were retrospectively collected. Patients were contacted by outpatient clinic controls for mid-term results.

RESULTS

The male/female ratio was 10/11. The mean age of the patients was 71.0 ± 6.4 years. Preoperative and postoperative left ventricular ejection fraction was statistically similar (P = 0.973). Early postoperative MR grade (mean, 0.57 ± 0.51) was statistically lower than the preoperative MR grades (mean, 3.38 ± 0.50) (P < 0.001). There was no revision for excess bleeding. Two patients had prolonged hospitalization, one for sternal infection and the other for severe chronic obstructive pulmonary disease. No hospital or late postoperative deaths occurred. The mean late postoperative MR grade was 0.66 ± 0.97 degrees. One patient had progression of MR in the later follow-up, which was treated by mitral valve replacement.

CONCLUSION

Semicircular reduction annuloplasty is an effective, inexpensive and easy surgical annuloplasty technique with low mortality and morbidity in severe symptomatic ischemic MR.

Percutanenous therapies for mitral regurgitation

Percutaneous therapies for the treatment of mitral regurgitation have emerged rapidly over the past several years. Most of the percutaneous approaches are modifications of existing surgical approaches to mitral annuloplasty or leaflet repair. Most of the percutaneous devices are based on surgical approaches. Catheter-based leaflet repair with the MitraClip is accomplished using an implantable clip to mimic the surgical edge-to-edge technique. Percutaneous annuloplasty can be achieved indirectly via the coronary sinus, or directly from retrograde left ventricular access. Several of these percutaneous approaches have been successfully used in trials or are in the early stages of use in practice.

Percutaneous approaches to mitral regurgitation

Percutaneous therapy for mitral repair has emerged over the past several years as an investigational option for treating mitral regurgitation (MR). A variety of novel methods to treat MR using a percutaneous route have been developed. Most of these approaches are modifications of surgical techniques, some established and some obscure. The basic surgical approaches to mitral repair are annuloplasty and leaflet repair. Catheter-based devices mimic or approximate these surgical approaches. MR as a disease process is heterogeneous, and different therapeutic approaches are needed for different etiologies of MR and morphologies of the mitral apparatus. Primary leaflet diseases are mitral prolapse and fibroelastic deficiency. Secondary, or functional, MR exists when the leaflets are normal. Functional ischemic MR and functional MR related to heart failure occur in different populations and historically have had different responses to surgical therapy. Leaflet repair using a percutaneous clip has been accomplished for patients with mitral valve prolapse and also some patients with functional MR. Indirect annuloplasty via the coronary sinus has shown promising early human trial results in patients with functional MR. Direct annuloplasty and left ventricular chamber remodeling technologies are in the earliest stages of human application. This group of approaches is being studied as an alternative to surgery for selected patients. The MitraClip (Evalve, Menlo Park, CA) for leaflet repair has been approved for use in Europe and is being applied predominantly to high-risk surgical patients with either functional or degenerative, organic MR. One of the coronary sinus devices has received approval in Europe as well. This complex clinical landscape has made device development, trial design, and patient selection complicated. Steady progress in the field is being made. Many patients with functional MR who are currently treated medically will be the subject of upcoming trials. Catheter methods for mitral repair promise to serve some patients currently considered high risk for surgery, and some patients may have catheter therapy as an alternative to surgery.

Beating-heart mitral valve suture annuloplasty under real-time three-dimensional echocardiography guidance: an ex vivo study

We are developing an alternative mitral valve suture annuloplasty technique on the beating-heart under real-time three-dimensional echocardiography (RT3DE) guidance. The purpose of this initial study was to evaluate a feasibility of this technique using commercially available suturing devices (Sutur Tek Endo 360-degree, Sutur Tek Inc, North Chelmsford, MA, USA). Isolated porcine hearts (n=10) were mounted in a water-filled tank and attached to an ex vivo pulse simulation device, where varying left ventricle pressures with associated valve motion were generated by pulsatile flow through an apical cannula. The suturing device was inserted through the left atrium. Intra-annular (De Vega type) suture annuloplasty was performed under RT3DE guidance. The procedure was successfully performed in all cases. The diameter of the annulus was effectively reduced (85.5+/-4.2% of original antero-posterior dimension, 86.7+/-6.1% of original transverse dimension). The number of tissue bites was 7.4+/-0.8. The maximum distance between the annulus and sutures placed was 1.1 mm. The total procedure time was 9.4+/-2.4 min. There was no collateral tissue injury in any of the cases. This ex vivo study demonstrates the feasibility of beating-heart mitral valve suture annuloplasty under RT3DE guidance.

Simple suture mitral annuloplasty with left ventriculotomy

Surgical treatment of mitral regurgitation, especially when compounded by ventricular aneurysm, remains a challenge. Several procedures have been developed to repair the mitral valve and reduce regurgitation. We describe a technique of intraventricular annuloplasty which is much less time-consuming than mitral valve repair through a left atriotomy. This procedure is considered technically easy and useful.

[Surgery of the mitral valve--in the work of József Kudász]

The author described his results of surgical treatment of mitral valve disease. Of 57 patients, the isolated mitral procedure was performed in 72%, and the combined (valve and coronary) in 28% of the cases. In 75% of the patients valve repair, and in 25% valve replacement were performed. There were 2 cases (3.5%) of early mortality after combined surgery where patients had also ischaemic heart disease. All the replaced valve prostheses and 84% of repaired mitral valve had a normal function. The mitral regurgitation was moderate in 14%, of cases and mild in 2% of cases at the follow up, but no reoperation was needed. After the surgery 85% of patients had sinus rhythm, 13% had atrial arrhythmia and in 2% the pacemaker was needed. Attempt of valve repair had to be made in all patients with mitral valve disease which can be performed in almost every case of degenerative valve prolapse and the rupture of chordae tendineae.

Evaluation of techniques and outcomes of mitral valve repair in dogs

OBJECTIVE

To describe surgical techniques for and assess outcome of treatment of mitral regurgitation in dogs.

DESIGN

Uncontrolled prospective study.

ANIMALS

18 dogs with naturally occurring mitral regurgitation.

PROCEDURE

All dogs weighed > 5 kg (11 lb) and had severe mitral regurgitation, congestive heart failure (CHF), and no serious noncardiac disease. Left ventricular volume indices, left atrial size, and degree of mitral regurgitation were determined echocardiographically before and after surgery. Repair techniques included circumferential annuloplasty, placement of artificial chordae, chordal fenestration and papillary muscle splitting, and edge-to-edge repair. Factors predictive for surgery survival and resolution of CHF were determined.

RESULTS

12 dogs survived surgery. Factors predictive for surgery survival included weight > 10 kg (22 lb) and CHF of less than 6 months' duration. In 9 dogs, CHF resolved for a median period of 1 year (range, 4 months to 3 years) after surgery. One dog had stable CHF at 12 months. One dog died as a result of progressive CHF; another was euthanatized for a noncardiac reason. Left ventricular diastolic volume index was 226.9 +/- 117.7 cm3/m2 before surgery and 134.9 +/- 70.4 cm3/m2 at 6 months after surgery (n = 10). Factors predictive for resolution of CHF included left ventricular diastolic volume index < 250 cm3/m2 and systolic volume index < 70 cm3/m2.

CONCLUSION AND CLINICAL RELEVANCE

Mitral valve repair may resolve CHF in dogs with severe mitral regurgitation, particularly in dogs that weigh > 10 kg and are treated within 6 months of the onset of CHF.