Mitral-valve repair without annuloplasty rings: results after repair of anterior leaflet versus posterior-leaflet defects using polytetrafluoroethylene sutures for chordal replacement.

OBJECTIVE: Defects of the anterior mitral leaflet (AML), including ruptured chordae, are often regarded as difficult or even impossible to repair. Chordal replacement may also be an option in extensive disease of the posterior mitral leaflet (PML). It has not yet been clearly defined whether the repair of either mitral leaflet using chordal-replacement techniques is as safe as the standard repair of the mitral valve (MV) including quadrangular resection and ring reduction alone. METHODS: Between October 1995 and June 1999, 160 patients underwent MV repair for mitral regurgitation (MR) in our institution. Chordal replacement with polytetrafluoroethylene (PTFE) sutures for elongated or ruptured chordae was performed in 72 (45%) patients. These patients were divided into two groups according to the location of the MV lesions: 48 patients with prolapse of the anterior or both leaflets (AML group) received an average of 2.2+/-1. 1 PTFE sutures for repair; in 24 patients with isolated PML defects (PML group), we used an average of 1.5+/-0.8 PTFE sutures. No prosthetic annuloplasty rings were used. Dilatation of the posterior mitral ring was corrected by PTFE suture annuloplasty. The remaining 88 patients underwent a standard mitral repair without chordal replacement. There were no statistically significant (NS) differences between the two groups (AML/PML) regarding age (59/62 years, P=0.49), left ventricular (LV) ejection fraction (64/66%, P=0. 6) and preoperative NYHA class (2.9/2.9, P=0.36). Postoperatively, all patients were followed by serial transthoracic echocardiography at 1 week and after 3, 6, 12 and 24 months by the same investigator. RESULTS: In-hospital mortality was 4.2% (2/48) in the AML group and 0% (0/24) in the PML group (P=0.55). Three of the AML patients (6. 3%) and one PML patient (4.2%) underwent reoperation for recurrent MR (P=1.0). The 1- and 2-year freedom from MV reoperation was 95. 1+/-3.4 and 92.6+/-4.2% in the AML group versus 95.0+/-4.9 and 95. 0+/-4.9% (P=0.67). The 1- and 2-year freedom from residual or recurrent MR grade 2 or higher was 97.6+/-2.4 and 94.9+/-3.5% (AML) versus 95.8+/-4.0 and 95.8+/-4.0% (PML) (P=0.97). CONCLUSIONS: We were unable to find statistically significant differences concerning mortality, freedom from recurrent MR and MV reoperation between the AML and PML groups. Extensive prolapse or chordal pathology of the anterior and PML can be corrected by chordal replacement. Using these techniques, stable repair can be achieved in more than 90% of patients at mid-term follow-up. Long-term observations are necessary to confirm the durability of this type of MV repair.     

Systolic anterior motion of the mitral valve despite the sliding leaflet technique for repair of the mitral valve

We report a systolic anterior motion of the anterior mitral leaflet despite employing the sliding leaflet technique for repair of mitral valve regurgitation. A 65-year-old man with chronic, symptomatic mitral regurgitation due to ruptured chordae tendineae underwent mitral valve repair by quadrangular resection of the posterior leaflet and sliding leaflet technique with ring annuloplasty. After weaning from cardiopulmonary bypass, left ventricular outflow obstruction developed and transesophageal echocardiography demonstrated systolic anterior motion of the mitral valve and severe mitral regurgitation. Non-operative treatment resolved the outflow tract obstruction, systolic anterior motion and mitral regurgitation. We conclude that post-repair systolic anterior motion can still occur after the sliding plasty procedure and that medical treatment can successfully resolve systolic anterior motion and outflow tract obstruction in most patients.     

Early and late results of partial plication annuloplasty for congenital mitral insufficiency

BACKGROUND: Partial plication annuloplasty is the main technique for congenital mitral insufficiency because this technique allows the mitral anulus to grow, in contrast to ring annuloplasty. However, this technique is not satisfactory for mitral insufficiency with some anomalies of the mitral valve apparatus. METHODS: Forty-one patients underwent partial plication annuloplasty for mitral regurgitation from July 1979 to December 1998. Mitral regurgitation associated with an atrioventricular defect, an atrioventricular discordance, and a univentricular heart was excluded from this study. RESULTS: There were no early or late deaths. In early results, partial plication annuloplasty was more effective for mitral regurgitation with abnormality of the posterior leaflet (n = 14) or normal leaflet motion (n = 8) than with abnormality of the anterior leaflet and its apparatus (n = 14) or absence of chordae (n = 4). The mean follow-up period was 145.8 months. During the follow-up period, 2 patients underwent mitral valve replacement, and a third patient underwent mitral valve repair with partial plication annuloplasty after the first repair. The main cause of mitral regurgitation of 2 of the 3 patients was absence of chordae. The actuarial freedom from reoperation rate was 94.9% +/- 3.6%, 91.9% +/- 4.7%, and 91.9% +/- 4.7% at 5, 10, and 15 years after the operation, respectively. CONCLUSION: Early and long-term results of partial plication annuloplasty were acceptable for congenital mitral insufficiency with any type of malformation of the mitral valve, and results were excellent with abnormality of the posterior leaflet and its apparatus or normal leaflet motion. However, late results were suboptimal for mitral regurgitation with absence of chordae. Other techniques, such as artificial chorda replacement, should be adapted in these cases.     

The effects of ring annuloplasty on mitral leaflet geometry during acute left ventricular ischemia

BACKGROUND: The perturbed mitral leaflet geometry that leads to acute ischemic mitral regurgitation during acute left ventricular ischemia has not been quantified, nor is it known whether annuloplasty rings affect these detrimental changes in leaflet geometry. METHODS: Radiopaque markers were implanted on both mitral leaflets and around the anulus in 3 groups of sheep: one group without rings served as the control group (n = 7); the others underwent Duran (n = 6; Medtronic Heart Valve Division, Minneapolis, Minn) or Carpentier-Edwards Physio (n = 5; Baxter Cardiovascular Division, Santa Ana, Calif) ring annuloplasty. After recovery, 3-dimensional marker coordinates were obtained by means of biplane videofluoroscopy before and during acute posterolateral left ventricular ischemia. Leaflet geometry was defined by measuring distances between annular and leaflet markers and perpendicular distances to the leaflet markers from a best-fit annular plane. RESULTS: In all control animals, left ventricular ischemia was associated with acute ischemic mitral regurgitation and apical displacement (away from the annular plane) of the posterior leaflet edge and base markers by 0.6 +/- 0.4 mm (P =.01) and 0.7 +/- 0.2 mm (P <.001), respectively. The distance between the posterior leaflet markers and the mid-posterior anulus did not change significantly during ischemia. The anterior leaflet edge marker extended 1.0 +/- 0. 5 mm (P =.01) away from the mid-anterior anulus during ischemia, but compared with its nonischemic position, the anterior leaflet was not displaced apically away from the annular plane. In all animals in the Duran and Physio groups, leaflet geometry was unchanged during ischemia, and acute ischemic mitral regurgitation was not detected. CONCLUSION: Acute ischemic mitral regurgitation was associated with restricted motion of the posterior leaflet and extension of the anterior leaflet. Annuloplasty rings prevented these geometric perturbations of the mitral leaflets during acute left ventricular ischemia and preserved valvular competence.     

Mitral valve repair for degenerative disease: is pericardial posterior annuloplasty a durable option?

OBJECTIVE: Biological and prosthetic rings are available for supporting mitral valve repair (MVR). Contrasting data are reported on the durability of pericardial ring annuloplasty. This retrospective study was undertaken to assess the durability of MVR for degenerative regurgitation with posterior annuloplasty performed with glutaraldehyde-treated autologous pericardium. METHODS: From August 1995 through December 2000, 133 patients underwent mitral repair for degenerative regurgitation (86 men, age 62.9+/-11.5 years). Thirty patients (22.6%) underwent combined coronary artery bypass graft and fourteen (10.5%) underwent tricuspid annuloplasty. Associated aortic disease, previous cardiac surgery and endocarditis were considered exclusion criteria. RESULTS: Seventy-seven patients (57.9%) received a Carpentier-Edwards ring and 56 received (42.1%) an autologous pericardium ring. Thirty-day mortality was 3.8%. Mean follow-up, 98.3% complete, was of 35.6+/-18.7 months. Five-year freedom from reoperation and recurrence of mitral regurgitation> or =3+/4+ was significantly higher in the prosthetic ring group (90.1% - CL90%: 81.9-98.3%) compared with the pericardial ring group (62.6% - CL90%: 43.1-82.1%; P=0.027). Prosthetic ring implantation (P=0.004; RR=0.11) and preoperative New York Heart Association (NYHA) class< or =II (P=0.011; RR=0.16) were independently related to a lower risk of reoperation and recurrence of mitral regurgitation> or =3+/4+, by multivariate analysis. Five-year overall survival was 91.4% (CL90%: 87.9.7-95%). A higher preoperative left ventricular end-diastolic diameter (P=0.006; RR=1.17) and the severity of associated coronary artery disease (P=0.021; RR=2.00) were independent predictive factors for poor survival by multivariate analysis. CONCLUSIONS: Posterior pericardial annuloplasty can jeopardize reproducibility and durability of MVR for degenerative regurgitation.     

Annuloplasty ring selection for chronic ischemic mitral regurgitation: lessons from the ovine model

BACKGROUND: Chronic ischemic mitral regurgitation (CIMR) is poorly understood and repair operations are often unsatisfactory. This study elucidates the mechanism of CIMR in an ovine model. METHODS: Sonomicrometry array localization measured the three-dimensional geometry of the mitral annulus and subvalvular apparatus in five sheep before and 8 weeks after a posterior infarction of the left ventricle that produced progressive severe CIMR. RESULTS: End systolic annular area increased from 647 +/- 44 mm(2) to 1,094 +/- 173 mm(2) (p = 0.01). Annular dilatation occurred equally along the anterior (47.0 +/- 5.6 mm to 60.2 +/- 4.9 mm, p = 0.001) and posterior (53.8 +/- 3.1 mm to 68.5 +/- 8.4 mm, p = 0.005) portions of the annulus. The tip of the anterior papillary muscle moved away from both the anterior and posterior commissures by 5.2 +/- 3.2 mm (p = 0.021) and 7.3 +/- 2.2 mm (p = 0.002), respectively. The distance from the tip of the posterior papillary muscle to the anterior commissure increased by 11.0 +/- 5.7 mm (p = 0.032) while the distance from the tip of the posterior papillary muscle to the posterior commissure remained constant. CONCLUSIONS: Progressive dilatation of both the anterior and posterior mitral annuli, increased annular area, and asymmetric ventricular dilatation combine to cause CIMR by distortion of mitral valve geometry and tethering of leaflet coaptation. Therefore complete ring annuloplasty may be superior to partial annuloplasty in the treatment of CIMR.     

Tricuspid valve repair: durability and risk factors for failure

OBJECTIVES: To compare durability of tricuspid valve annuloplasty techniques, identify risk factors for repair failure, and characterize survival, reoperation, and functional class of surviving patients. METHODS: From 1990 to 1999, 790 patients (mean age 65 +/- 12 years, 51% New York Heart Association functional class III or IV, and mean right ventricular systolic pressure 56 +/- 18 mm Hg) underwent tricuspid valve annuloplasty for functional regurgitation using 4 techniques: Carpentier-Edwards semi-rigid ring, Cosgrove-Edwards flexible band, De Vega procedure, and customized semicircular Peri-Guard annuloplasty. Of these patients, 89% had concomitant mitral valve surgery. A total of 2245 follow-up transthoracic echocardiograms were retrieved. Tricuspid regurgitation was analyzed, and risk factors for worsening regurgitation were identified, by multivariable ordinal longitudinal methods. RESULTS: Tricuspid regurgitation 1 week after annuloplasty was 3+ or 4+ in 14% of patients. Regurgitation severity was stable across time with the Carpentier-Edwards ring (P =.7), increased slowly with the Cosgrove-Edwards band (P =.05), and rose more rapidly with the De Vega (P =.002) and Peri-Guard (P =.0009) procedures. Risk factors for worsening regurgitation included higher preoperative regurgitation grade, poor left ventricular function, permanent pacemaker, and repair type other than ring annuloplasty. Right ventricular systolic pressure, ring size, preoperative New York Heart Association functional class, and concomitant surgery were not risk factors. Tricuspid reoperation was rare (3% at 8 years), and hospital mortality after reoperation was 37%. CONCLUSIONS: Tricuspid valve annuloplasty did not consistently eliminate functional regurgitation, and across time regurgitation increased importantly after Peri-Guard and De Vega annuloplasties. Therefore, these repair techniques should be abandoned, and transtricuspid pacing leads should be replaced with epicardial leads.     

Posterior mitral annuloplasty using autologous pericardium in the repair of posterior leaflet prolapse

Objective: Mitral valve repair is frequently performed now because it produces a favorable postoperative quality of life, as well as improved cardiac function. For the treatment of posterior leaflet prolapse, we perform a posterior mitral annuloplasty using an autologous pericardium. The present study assessed the efficacy of this operation. Methods: From April 1999 to October 2003, 42 patients underwent a posterior mitral annuloplasty using autologous pericardium for the treatment of posterior leaflet prolapse. There were 15 men and 27 women with an average age of 63.9 ±11.8 years. The length of the autologous pericardium matched the length of the posterior leaflet annulus as measured with Carpentier-Edwards ring sizer that was chosen based on the area of the anterior leaflet. Results: The average size of the Carpentier-Edwards ring sizer that was used to determine the length of the autologous pericardium was 27.7±1.3 mm, and the absolute length of the pericardium was 50.9±1.8 mm, and the average intra-operative jet area, as assessed by transesophageal echocardiography, was 0.36±0.47 cm². The five-year freedom from reoperation was 97.1%, while the freedom from significant residual mitral regurgitation (≥3+/4+) was 92.0%. Two patients (4.8%) developed systolic anterior motion, and one patient (2.4%) had a cerebral infarction. None of the patients died after surgery, and no patients developed complications such as hemolysis or ring detachment. Conclusions: Posterior mitral annuloplasty using an autologous pericardium was shown to be a superior technique because it allows a sufficient annular repair with no complications such as hemolysis or ring detachment. Read at the Fifty-sixth Annual Meeting of the Japanese Association for Thoracic Surgery, Symposium, Tokyo, November 19–21, 2003.     

Late results of mitral valve repair for mitral regurgitation

OBJECTIVE: This study was undertaken to evaluate the long-term results of mitral valve repair for mitral regurgitation. METHODS: Between 1991 and 2000, 301 patients with mitral regurgitation underwent mitral valve repair. There were 167 men and 134 women whose mean age was 56 +/- 14 years. The patients were comprised of 7 patients in Carpentier's type I, 277 patients in type II, and 17 patients in type III. Chordal replacement with expanded polytetrafluoroethylene sutures had been prospectively applied to repair the anterior mitral leaflet prolapse. Ring annuloplasty was performed in 230 patients (76%). The follow-up was complete and mean follow-up was 67 +/- 33 months, for a cumulative follow-up of 1,624 patient-years. RESULTS: There were 5 hospital deaths and 11 late deaths (2 cardiac and 9 noncardiac). All survivors except those with stroke were in the New York Heart Association (NYHA) functional class I or II. At 10 years, the actuarial survival was 90 +/- 3%, the freedom from embolism was 86 +/- 4%, the freedom from reoperation was 96 +/- 2%, and the freedom from valve-related events was 77 +/- 4%. At 10 years, the freedom from reoperation in the patients with anterior leaflet prolapse was 90 +/- 5%. CONCLUSIONS: Mitral valve repair is feasible in most patients with mitral regurgitation and is associated with low mortality and low rates of valve related events. Chordal replacement with expanded polytetrafluoroethylene sutures is effective, safe, and durable at long-term follow-up for patients with anterior leaflet prolapse.     

线圈法人工腱索植入治疗二尖瓣关闭不全的近中期疗效分析

目的 总结线圈法人工腱索植入治疗二尖瓣脱垂导致的瓣膜关闭不全的临床经验。 方法 北京安贞医院心外科2008年1月至2011年8月应用线圈法人工腱索植入治疗二尖瓣关闭不全的患者共22例,男15例、女7例,年龄26～69 （53.1±8.5） 岁。心功能分级（NYHA） Ⅱ级6例,Ⅲ级16例。前叶腱索断裂14例,前叶腱索延长2例,前后叶腱索均有断裂4例,后叶腱索断裂2例。均合并重度以上二尖瓣反流,1例合并三房心,1例合并冠心病。左心室舒张期末内径49～67 （58.1±3.9） mm,射血分数（EF） 58%～69% （61.8%±6.1%）,心胸比率0.53±0.16。应用自制的腱索测量器,测量病变腱索邻近正常腱索的长度作为人工腱索的长度,根据瓣叶脱垂的范围,在测量器上制作人工腱索线圈数根,然后将其固定在相应乳头肌和脱垂瓣叶游离缘,常规进行瓣环成形。同期行三房心矫治术1例,冠状动脉旁路移植术1例。所有患者出院后华法林抗凝治疗3个月。 结果 无手术死亡,术后出现血红蛋白尿1例,伤口感染1例,经治疗后均痊愈。出院前超声心动图提示无反流或微量反流1例,微量反流21例。术后左心室舒张期末内径43～53 （48.3±2.1） mm,较术前明显改善。术后门诊随访4～39 （18.3±5.2） 个月,少量反流5例,无或微量反流17例。心功能分级（NYHA） Ⅰ级17例,Ⅱ级5例,较术前明显改善。 结论 线圈法人工腱索植入治疗二尖瓣脱垂所致的二尖瓣关闭不全,手术操作简单易行,近中期疗效满意。     

Correction of anterior mitral prolapse. Results of chordal transposition.

From 1986 to 1992 102 mitral valve repairs were done for mitral regurgitation due to a degenerative disease. Forty-eight patients had an anterior prolapse or prolapse of both leaflets at initial presentation and underwent chordal transposition from the mural leaflet to the anterior leaflet. The corrective procedure was completed by polytetrafluoroethylene or pericardial posterior annuloplasty. Operative mortality was 2.9%, and follow-up (average 22 months) was 100% complete. There were three postreconstruction valve replacements (one earlier and two later) for a probability of freedom from reoperation of 91.5% +/- 5.2% at 3 years. Freedom from all morbidity was 85.5% +/- 5.5% at 3 years. Postoperative echocardiographic studies demonstrated a good mitral valve function: (1) Eighty-seven percent of patients presented no or mild residual regurgitation; (2) transmitral flow indexes were within the norm; (3) left ventricular outflow tract flow was normal in all patients. This study shows that chordal transposition is a safe and effective technique for prolapse of anterior or both leaflets and improves the chances of repair in patients with mitral degenerative disease.     

Experience with twenty-eight cases of systolic anterior motion after mitral valve reconstruction by the Carpentier technique.

Systolic anterior motion of the mitral valve with left ventricular outflow tract obstruction after Carpentier-type mitral reconstruction with ring annuloplasty has led some surgeons to abandon an otherwise successful repair or to avoid use of a rigid ring. To assess the long-term significance of such motion, we studied 439 patients undergoing Carpenter mitral reconstruction at our institution between March 1981 and June 1990. The hospital mortality rate was 4.8% (21/439) overall and 3.7% (9/243) for isolated mitral reconstruction. Systolic anterior motion was found in 6.4% (28/438) after the operation, and 2.3% (10/438) had a coexisting left ventricular outflow tract gradient (mean 53 mm Hg). Of the 28 patients with systolic anterior motion, 27 (96.4%) had leaflet prolapse, 17 (60.7%) had undergone more than a 3 cm resection of the posterior leaflet, and two (7.1%) had preexisting idiopathic hypertrophic subaortic stenosis. All patients were treated medically, 14 with negative inotropic agents. Follow-up echocardiograms at a mean of 32 months demonstrated the disappearance of systolic anterior motion in 13 of 28 patients (46.4%) and resolution of the outflow tract gradient in 10 of 10 (100%). At follow-up only one patient was in New York Heart Association class III or IV and required reoperation for rheumatic mitral insufficiency. These data demonstrate that systolic anterior motion after Carpentier mitral reconstruction with ring annuloplasty is not prevalent and should be managed medically in most cases. Associated left ventricular outflow tract obstruction resolves with medical treatment.     

Long term results of mitral valve repair: posterior papillary muscle repositioning versus chordal shortening.

OBJECTIVE: Mitral valve repair is considered as the gold standard to treat mitral regurgitation. However anterior leaflet prolapse in the posterior paramedial and paracommissural area remains a challenging problem. Indeed several elongated chordae may arise from a single posterior papillary muscle head which does not allow safe separate chordal shortening (CS). We therefore suggest use of papillary muscle repositioning in such cases. METHODS: In a cohort of 180 mitral valve repair performed between 1989 and May 1998, we have retrospectively studied 100 consecutive patients who underwent anterior leaflet repair in the posterior paramedial and paracommissural area. Group I (n = 60) had posterior papillary muscle repositioning (PPMR) and group II (n = 40) had CS. There was no statistical difference between the two groups concerning age, functional class and left ventricular function. Etiology was similar in both groups, degenerative process being predominant. At echocardiogram, regurgitation was graded 3.4/4 in both groups. There was no statistical difference concerning preoperative ejection fraction, end systolic and end diastolic left ventricular diameter. RESULTS: There were no in-hospital deaths in group I and two deaths in group II not related to mitral valve repair. Mean follow up is 26.4 +/- 24.2 months in group I and 46.1 +/- 28.8 months in group II. No patient was lost to follow up. Severe mitral regurgitation was not observed. Mean regurgitation at follow up was 0.8 +/- 0.7 in group I and 0.8 +/- 0.8 in group II (P = n.s.); there was no statistical difference between the two groups concerning postoperative ejection fraction, end systolic and end diastolic left ventricular diameter. There was no late cardiac death in either group and there were no thromboembolic events. Actuarial survival rate is 100% and 94.4% in group I and 92% and 84.4% in group II at 2 and 6 years, respectively. CONCLUSION: This experience shows that PPMR provides as good longterm results as CS to repair anterior leaflet prolapse in posterior paramedial and paracommissural area with lesser morbidity and mortality.     

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

Between October, 1982, and December, 1984, 126 patients at the Texas Heart Institute underwent mitral valve repair for mitral insufficiency utilizing the Puig-Massana-Shiley annuloplasty ring. Resection of a triangular-shaped wedge of the mural leaflet and direct suture repair was done in 42 patients, and anterior leaflet repair was used in 2 patients. There were 79 male (63%) and 47 female (37%) patients with a mean age of 58 years. Preoperatively, 95% were in New York Heart Association (NYHA) Functional Class III or IV. Concomitant cardiac operations were performed in 82 patients and included coronary artery bypass grafting (49%), aortic valve replacement (16%), repair of ventricular septal defect (2%), resection of left ventricular aneurysm (2%), and repair of atrial septal defect (1%). There were 8 early deaths (6.3%) and 11 late deaths (8.7%). In 44 patients undergoing mitral valve repair as an isolated primary procedure, operative mortality was 2.3%. Murmurs of mitral insufficiency were present in 5 patients postoperatively, but only 1 required early reoperation for mitral valve replacement. Follow-up data have been obtained on 80% of the patients. Postoperative Functional Class was obtained for 63 of the 82 surviving patients and showed 92% of these patients to be in NYHA Functional Class I or II. Mitral valve repair incorporating the Puig-Massana-Shiley annuloplasty ring and valve leaflet revision is a reliable technique that is not technically demanding. We believe these methods should be attempted for correction of pure mitral insufficiency, particularly in circumstances where other cardiac repairs are required.     

Evolving techniques for mitral valve reconstruction

OBJECTIVE: To analyze the effectiveness of new techniques of mitral valve reconstruction (MVR) that have evolved over the last decade, such as aggressive anterior leaflet repair and minimally invasive surgery using an endoaortic balloon occluder. SUMMARY BACKGROUND DATA: MVR via conventional sternotomy has been an established treatment for mitral insufficiency for over 20 years, primarily for the treatment of patients with posterior leaflet prolapse. METHODS: Between June 1980 and June 2001, 1,195 consecutive patients had MVR with ring annuloplasty. Conventional sternotomy was used in 843 patients, minimally invasive surgery in 352 (since June 1996). Anterior leaflet repair was performed in 374 patients, with increasing use over the last 10 years. Follow-up was 100% complete (mean 4.6 years, range 0.5-20.5). RESULTS: Hospital mortality was 4.7% overall and 1.4% for isolated MVR (1.1% for minimally invasive surgery vs. 1.6% for conventional sternotomy; =.4). Multivariate analysis showed the factors predictive of increased operative risk to be age, NYHA functional class, concomitant procedures, and previous cardiac surgery. The 5-year results for freedom from cardiac death, reoperation, and valve-related complications among the 782 patients with degenerative etiology are, respectively, as follows ( >.05 for all end points): for anterior leaflet repair, 93%, 94%, 90%; for no anterior leaflet repair, 91%, 92%, 91%; for minimally invasive surgery, 97%, 89%, 93%; and for conventional sternotomy, 93%, 94%, 90%. CONCLUSIONS: These findings indicate that late results of MVR after minimally invasive surgery and after anterior leaflet repair are equivalent to those achievable with conventional sternotomy and posterior leaflet repair. These options significantly expand the range of patients suitable for mitral valve repair surgery and give further evidence to support wider use of minimally invasive techniques.     

Ischemia in three left ventricular regions: Insights into the pathogenesis of acute ischemic mitral regurgitation

BACKGROUND: Acute posterolateral left ventricular ischemia in sheep results in ischemic mitral regurgitation, but the effects of ischemia in other left ventricular regions on ischemic mitral regurgitation is unknown. METHODS: Six adult sheep had radiopaque markers placed on the left ventricle, mitral annulus, and anterior and posterior mitral leaflets at the valve center and near the anterior and posterior commissures. After 6 to 8 days, animals were studied with biplane videofluoroscopy and transesophageal echocardiography before and during sequential balloon occlusion of the left anterior descending, distal left circumflex, and proximal left circumflex coronary arteries. Time of valve closure was defined as the time when the distance between leaflet edge markers reached its minimum plateau, and systolic leaflet edge separation distance was calculated on the basis of left ventricular ejection. RESULTS: Only proximal left circumflex coronary artery occlusion resulted in ischemic mitral regurgitation, which was central and holosystolic. Delayed valve closure (anterior commissure, 58 +/- 29 vs 92 +/- 24 ms; valve center, 52 +/- 26 vs 92 +/- 23 ms; posterior commissure, 60 +/- 30 vs 94 +/- 14 ms; all P <.05) and increased leaflet edge separation distance during ejection (mean increase, 2.2 +/- 1.5 mm, 2.1 +/- 1.9 mm, and 2.1 +/- 1.5 mm at the anterior commissure, valve center, and posterior commissure, respectively; P <.05 for all) was seen during proximal left circumflex coronary artery occlusion but not during left anterior descending or distal left circumflex coronary artery occlusion. Ischemic mitral regurgitation was associated with a 19% +/- 10% increase in mitral annular area, and displacement of both papillary muscle tips away from the septal annulus at end systole. CONCLUSIONS: Acute ischemic mitral regurgitation in sheep occurred only after proximal left circumflex coronary artery occlusion along with delayed valve closure in early systole and increased leaflet edge separation throughout ejection in all 3 leaflet coaptation sites. The degree of left ventricular systolic dysfunction induced did not correlate with ischemic mitral regurgitation, but both altered valvular and subvalvular 3-dimensional geometry were necessary to produce ischemic mitral regurgitation during acute left ventricular ischemia.     

Long-term follow-up after Carpentier-Edwards ring annuloplasty for tricuspid regurgitation

BACKGROUND: Use of flexible rings for tricuspid ring annuloplasty is becoming popular. This study was undertaken to evaluate Carpentier-Edwards (C-E) rigid ring annuloplasty for tricuspid regurgitation (TR), secondary to mitral valve disease and clinical outcome on a long-term basis. METHODS: From December 1985 to March 1996, 45 patients with secondary TR underwent C-E ring annuloplasty. Thirty-nine patients (95.1%) were in New York Heart Association (NYHA) functional class III or IV. The mean follow-up was 96.7+/-48.5 months or 362.6 patient-years. RESULTS: There were three in-hospital and nine late deaths that were not related to tricuspid annuloplasty. Actuarial survival at 10 years was 68.3%. Echocardiographic studies showed that TR was well controlled within grade 2+ in all survivors. Residual pulmonary hypertension (PH) was recognized in 9 of 21 patients (42.9%) with preoperative PH, however, no TR was seen in 6 patients. A TR grade of 2+ was observed in 3 patients. Thirty of the total survivors (96.8%) were in NYHA class I and II, but 1 patient was in NYHA class III. The actuarial rate of freedom from tricuspid valve reoperation after 10 years was 97.5%. CONCLUSIONS: C-E ring annuloplasty is acceptable for repair of secondary TR and improvement in clinical status on a long-term basis.     

The rheumatic mitral valve and repair techniques in children

The mitral valve is the most commonly affected valve in acute and chronic rheumatic heart disease in the first and second decades of life. Pure or predominant mitral regurgitation with non-significant stenosis (mitral valve area > 1.5 cm(2) on echocardiography) is the most frequently encountered valvular dysfunction in children. In our experience, based on 428 children operated between 1993 and 2011 at our institution, functional classification based on leaflet motion assessed by echocardiography and reconfirmed peroperatively revealed pure annulus dilatation (type I) in 7% of patients, anterior leaflet prolapse (type IIa) in 33%, combination of anterior leaflet pseudoprolapse with restricted motion of the posterior leaflet (type pseudoIIa/IIIp) in 34%, and restricted anterior and posterior leaflet motion (type IIIa/p) in 26%. Patients with type III were older than those with type IIa and type pseudoIIa/IIIp. Different techniques can be used to repair rheumatic mitral valve lesions: prolapse of the anterior leaflet caused by chordal elongation or rupture can be treated by chordal shortening, chordal transfer, or artificial chordal replacement; restricted motion of the anterior and/or posterior leaflet can be treated by commissurotomy, splitting of the papillary muscles, resection of the secondary, or sometimes primary posterior chordae, posterior leaflet free edge suspension, leaflet thinning, and leaflet enlargement using autologous pericardium. Because mitral annulus dilatation is present in almost all patients with mitral regurgitation, concomitant ring annuloplasty offers more stability in valve repair, improving long-term outcome. The major causes for failure of rheumatic mitral valve repair are the presence of ongoing rheumatic inflammation at the time of surgery, use of inappropriate techniques, technical failures requiring early reoperation, lack of concomitant ring annuloplasty, and progression of leaflet and chordal disease further resulting in more leaflet retraction, thickening, and deformity. Freedom from reoperation depends on mitral regurgitation functional type, the type IIa and type pseudoIIa/IIIp having a better long-term outcome than type I and type III, in our series. In conclusion, mitral valve repair should be a preferred strategy in children with rheumatic heart disease whenever feasible, providing stable actuarial survival with fewer thromboembolic complications in a pediatric population noncompliant to anticoagulation.     

Potential mechanism of left ventricular outflow tract obstruction after mitral ring annuloplasty

OBJECTIVES: The purpose of this study was to explore whether geometric changes that predispose to left ventricular outflow tract obstruction after mitral ring annuloplasty are coupled to subvalvular apparatus disturbances. METHODS: Radiopaque markers were implanted in sheep: 9 in the ventricle, 1 in the high interventricular septum, 1 on each papillary muscle tip, 8 around the mitral anulus, 4 on the anterior mitral leaflet, and 2 on the posterior leaflet. One group served as control (n = 5); the others were randomized to undergo annuloplasty with the Duran ring (n = 6; Medtronic, Inc, Minneapolis, Minn) or Carpentier-Edwards Physio ring (n = 6; Baxter Healthcare Corp, Irvine, Calif). After a 7- to 10-day recovery period, 3-dimensional marker coordinates were measured with biplane videofluoroscopy. RESULTS: At the beginning of ejection, (1) the anterior leaflet was displaced toward the left ventricular outflow tract; (2) the normal atrially flexed anterior anulus was flattened into the left ventricular outflow tract; (3) the posterior anulus was displaced toward the left ventricular outflow tract; (4) the anterior papillary muscle was displaced septally; and (5) the posterior papillary muscle was dislocated inwardly toward the anterior papillary muscle in the Physio ring group compared with the control group. During ejection, all these structures moved septally, encroaching further on the left ventricular outflow tract. In the Duran ring group, only the posterior anulus was displaced toward the left ventricular outflow tract; the anterior leaflet was not displaced toward the left ventricular outflow tract, and it did not move septally during ejection. CONCLUSIONS: The semirigid Physio ring was associated with perturbations in annular dynamics that caused changes in papillary muscle geometry. We propose an integrated valvular-subvalvular mechanism to explain displacement of the anterior leaflet into the left ventricular outflow tract after mitral ring annuloplasty.     

"Edge-to-edge" repair for anterior mitral leaflet prolapse

The aim of this study is to report our results in a series of 150 consecutive patients (mean age 53 +/- 15.4 years) in whom mitral regurgitation (MR) due to isolated anterior mitral leaflet (AML) prolapse was corrected using the edge-to-edge (E to E) technique over a period of more than 10 years. At admission, 49 (32.6%) patients were in NYHA class I, 46 (30.6%) in II, 51 (34%) in III and 4 (2.6%) in IV. In the great majority of the cases (111 patients, 74%), degenerative disease was the cause of MR. Hospital mortality was 0.6% (1/150). There were 7 late deaths. The actuarial overall survival and freedom from reoperation at 9 years were 91.6% +/- 3.16% and 96.6% +/- 1.74%, respectively. At follow-up (4.5 +/- 3.21 years, range 2 months-12 years), the mean mitral valve area was 2.7 +/- 0.5 cm(2) and mitral regurgitation was absent or mild in 132 patients (88%). The results of this study demonstrate the effectiveness and durability of the E to E repair in the setting of AML prolapse. In our institution, this technique, in conjunction with annuloplasty, remains the method of choice to correct segmental prolapse of the AML.