Mitral valve replacement with bileaflet preservation: a modified technique (original) (raw)
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Journal of Cardiac Surgery, 2004
Background: Satisfactory results of bileaflet preserving mitral valve replacement (MVR) had forced several institutes to preserve both leaflets during MVR. Modifications were required to prevent the preserved tissue from interfering with prosthetic valve function, to implant an adequate size of valve and to prevent left ventricle outflow tract (LVOT) obstruction. Materials and Methods: Conventional MVR was performed to 51 patients (group 1) and bileaflet preserving MVR was performed to 43 patients (group 2). Mitral anterior leaflet incised from the middle of the leaflet to mitral annulus without chordal injury in group 2 patients. Sutures were placed through the mitral annulus first and then passed from the bottom to the tip of anterior leaflet. Posterior leaflet was also preserved. Prosthetic valve was put down into the mitral annulus and sutures were ligated. Excessive anterior leaflet tissue was attached to left atrial wall. Results: Cross-clamping time was 45 ± 5.33 minutes versus 61.32 ± 4.43 minutes (p = 0.0001) and total cardiopulmonary bypass time was 60.80 ± 4.44 minutes versus 80.55 ± 3.65 minutes (p = 0.0001) in groups 1 and 2, respectively. Inotropy requirement was higher in group 1 (p = 0.0058). When compared with preoperative values postoperative left ventricle ejection fraction (LVEF) increased both at rest (from 52.74% ± 3.88% to 62.86% ± 3.18%, p = 0.0001) and during exercise (from 53.16% ± 3.16% to 64.11% ± 2.46%, p = 0.0001) in bileaflet preserving MVR group. But in conventional MVR group LVEF decreased postoperatively both at rest (from 51.45% ± 4.27% to 48.27% ± 3.35%, p = 0.0001) and during exercise (from 54.47% ± 7.36% to 42.96% ± 3.58%, p = 0.0001). Conclusion: Leaflet preserving MVR operation not only improves the left ventricular performance but also reduces the mortality and morbidity after MVR. LVEF increases both at rest and during exercise. Risk of LVOT obstruction can be completely eliminated with our simple technique
We present five cases of mitral bileaflet prosthesis dysfunction as a result of a stuck leaflet in closed position, diagnosed at surgery or during the first postoperative year. Methods and results: The diagnosis was made by echocardiography and could be confirmed by fluoroscopy in three patients. All cases had in common an early occurrence and the presence of a clean prosthesis by transesophageal echocardiography (TEE). In one patient the diagnosis was made by intraoperative TEE, and the problem could be solved by rotation of the occluding device. In the other four patients the diagnosis was made postoperatively and different strategies of treatment were taken. All but one case were reoperations, one had a dysfunctional biological prosthesis and three had been submitted to mitral valvoplasty (two rheumatic and one degenerative valves). According to our policy, patients started sodium warfarin therapy 24 h after surgery in order to keep International normalized ratio (INR) values between 2.5-3.5. Only in one case the presence of thrombusypannus could be confirmed. Conclusions: We call the attention to causes other than thrombosis that can provoke leaflet block and to the importance of performing intraoperative TEE in patients submitted to mitral valve replacement. We also emphasize the fact that a stuck leaflet in a clean prosthesis can evolve without major symptoms or cardiac events.
Journal of the Egyptian Society of Cardio-Thoracic Surgery, 2018
Background: To evaluate the long term results of two simple techniques for correction of posterior or bileaflet prolapse with no incidence of postoperative systolic anterior motion of the anterior mitral leaflet (SAM). Methods: From June 2010 to June 2016, 64 patients underwent mitral valve repair. Edge to edge,(35 patients)(group A) Vs. ('U') technique, (29 patients) (group U). A mean follow-up of 58 ± 13 months in (group A) and 42 ± 16 months in (group U). Results: There were no early or late deaths. Both surgical techniques showed excellent immediate postoperative results regarding reduction of the mitral regurgitation gradeaccepted mean pressure gradients (MPG) through the mitral valve (2.3 ± 0.6). Left ventricular function was maintained, and tricuspid regurgitation grade was reduced overall. During the follow-up period, Significant increase in the MPG was observed in (group A) with no significant change in the degree of mitral regurge. The majority of them with significant increase are due to the rheumatic pathology(9/12). They became symptomatic and came out of the study after a follow up period of 41 ± 13 months and their valves were replaced while those with non rheumatic pathology remained of reasonable gradient. Redo mitral valve replacement was done in only one patient in (group U) due to early endocarditis. Conclusions: Despite the rationale is completely different in both techniques (double orifice, double leaflet(A) versus Uni-leaflet, Uni-orifice(U)), the long-term results are comparable in both. The U technique is mostly better in rheumatic patients but need more follow up on larger scales of this patient group.
2014
OBJECTIVE: Although mitral valve repair is the preferred treatment for degenerative mitral valve disease, valve replacement still remains prevalent, particularly in the setting of anterior leaflet prolapse. We sought to determine the feasibility and mid-term durability of a lesion-based surgical strategy applied systematically in a consecutive and nonexclusionary (all comers) series of patients with degenerative mitral valve disease and either isolated anterior leaflet or bileaflet prolapse. METHODS: From January 2002 to December 2010, 188 consecutive patients [mean age 56 ± 14 years (range 12-86), 31% female, mean left ventricular ejection fraction 55 ± 9%] underwent surgery for degenerative anterior mitral leaflet prolapse [isolated (n = 42, 22%) or bileaflet prolapse (n = 146, 78%)]. Degenerative aetiology was Barlow's disease in 110 (58%) patients and fibroelastic deficiency in 78 (42%). RESULTS: Patients with anterior leaflet prolapse were significantly more symptomatic (New York Heart Association functional Class III-IV) than those with bileaflet prolapse (28.6 vs 9.6%; P = 0.003) at the time of surgery. All patients underwent mitral valve repair and ring annuloplasty. There was 1 immediate valve replacement due to atrioventricular groove bleeding and consequent haematoma in an elderly female patient (99.5% repair rate). Predominant repair techniques were polytetrafluoroethylene neochordoplasty (or loop technique) in 93 (49%) patients, chordal transfer in 86 (46%) and posterior leaflet flip technique in 21 (11%). Median length of stay was 6 (interquartile 5-8) days. In-hospital mortality was 1% (n = 2). Predischarge transthoracic echocardiography showed none to trace mitral regurgitation in 91% of the patients and mild mitral regurgitation in 9%. The Kaplan-Meier estimates for cumulative survival at 1 and 7 years were 98.4 ± 0.9 and 88.7 ± 2.2%, respectively. Freedom from ≥moderate mitral regurgitation was 100% at 1 year, 93.7 ± 2.2% at 4 years and 90.3 ± 3.7% at 7 years. When the interval-censored estimator was used, freedom from ≥moderate mitral regurgitation at 1, 4 and 7 years was 100, 96 and 92%, respectively. CONCLUSION: A lesion-based surgical approach with an intention to repair all degenerative valves with anterior leaflet prolapse was applied to a consecutive series of patients with degenerative mitral valve disease. We were able to achieve a near-100% repair rate. Repair of all degenerative valves may be feasible with good mid-term durability, regardless of valve morphology, patient age or comorbidities.
European Journal of Echocardiography, 2007
Acute prosthetic valve dysfunction due to leaflet escape is a mode of structural valve failure of mechanical prostheses which is associated with a high mortality. In this report, we describe the case of a 32-year-old patient, who underwent mitral valve replacement with a Tri-technologies bileaflet valve three years ago, and was admitted to the hospital on August 2005, in cardiogenic shock. He discontinued oral anticoagulation therapy four months ago. Transthoracic and transesophageal echocardiograms showed acute-onset massive mitral regurgitation with normal left ventricular function. The patient underwent emergency surgery, during which one leaflet was found to be absent and the other leaflet was fixed due to prosthetic thrombus.
Recurrent mitral regurgitation after mitral valve repair for bileaflet lesions in the modern era
Journal of Cardiothoracic Surgery, 2019
Background: Good mid-term durability of mitral valve repair of bileaflet lesions has been reported; however, patients may develop failure during follow-up. This study assessed late outcomes and mechanisms of failure associated with mitral valve repair of bileaflet lesions. Methods: Fifty-six patients (mean age 67 ± 12 years) underwent mitral valve repair of bileaflet lesions due to degenerative disease in 2011-2018. Mitral annuloplasty was added to all procedures except for 1 patient with annular calcification. Mitral valve lesions were identified by surgical inspection. Mean clinical and echocardiography follow-up occurred at 2.7 ± 2.1 and 2.5 ± 1.9 years, respectively. Results: Additional mitral valve repair techniques involved triangular resection (n = 15 patients), quadrangular resection with sliding plasty (n = 12), neochordoplasty (n = 52), and commissural plication (n = 26). Prolapse of ≥2 anterior and posterior leaflet scallops occurred in 22 (39%) and 30 (54%) patients, respectively. During follow-up, 10 (17.8%) patients developed moderate or severe mitral regurgitation. Whereas prolapse or tethering was observed early after neochordoplasty or quadrangular resection, recurrent regurgitation occurred late after commissural repair. Five-year freedom from recurrent moderate or severe mitral regurgitation rates was 71.1 ± 11.0%. Conclusions: Seventeen percent of patients developed recurrent mitral regurgitation during follow-up. Repair failure in the early phase occurred owing to aggressive resection of the posterior mitral leaflet or maladjustment of the artificial neochordae. Recurrent mitral regurgitation might occur in the late phase even after acceptable commissural repair. A sequential approach may be useful to improve the quality of mitral valve repair in bileaflet lesions.
European Journal of Cardio-Thoracic Surgery, 2012
Mitral valve replacement (MVR) in the presence of the extensive calcification of the mitral annulus is a technical challenge. The heavily calcified annulus can cause great difficulty in the insertion of a prosthetic valve and periprosthetic leakage later on. Vigorous annular decalcification may cause circumflex coronary artery injury, atrioventricular rupture and thromboembolic events. We herein describe a surgical technique for MVR in such cases while focusing on partial decalcification of the posterior mitral annulus and its reinforcement and buttressing with the transferred anterior mitral leaflet (AML). At the same time, the transferred AML supports the posterior annular region and maintains ventricular-annular continuity, thus preserving the left ventricular function.