Modified edge-to-edge technique for correction of congenital mitral regurgitation in infants and children

Since 2008, 28 patients with congenital mitral regurgitation have undergone mitral valve repair with a modified edge-to-edge technique at our institution. The regurgitant mitral leaflet was sutured with a pledget-reinforced, horizontal mattress suture with No. 4-0 polypropylene on the ventricle side and a pledget-reinforced mattress suture with Gore-Tex sutures (W.L. Gore & Associates, Flagstaff, AZ) and Dacron pledgets (Chest, Shanghai) placed on the anterior and posterior annulus corresponding to the edge-to-edge suturing site. Early results are encouraging, but a longer follow-up is needed.     

A case report on the repair of an anterior mitral leaflet chordal rupture using PTFE suture

Surgical repair of ruptured or elongated chordae tendineae of the mitral valve is one of the most complex reconstructive techniques in cardiac surgery. Various surgical procedures have been described to repair chordal abnormalities of the anterior leaflet of the mitral valve. This case report describes a simple repair technique with a double-armed, pledge-supported, expanded polytetrafluorethylene (PTFE) suture. A 48 year-old-man who had mitral regurgitation due to ruptured chordae tendineae of the anterior mitral leaflet underwent successful chordal reconstruction using 3--0 PTFE suture. Mitral regurgitation was completely repaired as shown by left ventriculogram and echo cardiogram more than one year postoperatively. In this experience, this procedure could be used to treat both elongated and ruptured chordae tendineae.     

Triangular plication of the anterior mitral leaflet: a new operative technique

This study describes the technique of triangular plication in patients with mitral valve incompetence that is due to segmental anterior leaflet prolapse. A nonabsorbable suture plicates the prolapsed leaflet area towards the ventricular aspect in a triangular fashion by decreasing the suture width towards the leaflet base. Because no leaflet tissue is resected, this technique allows for the intraoperative correction of an imperfect plication. Triangular plication was successful in all except one patient. In this patient, a failed repair was corrected with mitral valve replacement. Freedom from mitral valve incompetence of more than grade 0-I was 100% at 12 months and 86% at 36 months postoperatively.     

Generation of chordae tendineae with polytetrafluoroethylene stents. Results of mitral valve chordal replacement in sheep

Surgical repair of ruptured or elongated chordae tendineae of the mitral valve is one of the most complex reconstructive techniques in cardiac surgery. Various surgical procedures have been described to repair chordal abnormalities of the anterior leaflet of the mitral valve with unpredictable results. Mitral valve replacement is usually recommended in that situation. This report describes a simple repair technique that we have devised. We resected one or two marginal chordae of the anterior leaflet of the mitral valve in 35 sheep and replaced them with a double-armed, pledget-supported, expanded polytetrafluoroethylene suture. The 30 surviving animals were studied hemodynamically and were electively put to death 3, 6, 9, 18, and 24 months after the operation. Mitral insufficiency did not develop in any of the sheep. All specimens had a normal mitral valve without thrombosis. The polytetrafluoroethylene suture remained pliable and was incorporated into the anterior leaflet and papillary muscle. Scanning and transmission electron microscopy showed that the suture was completely covered by a sheath of tissue with a collagen structure remarkably similar to that of a native chorda. Calcification was not detected in the new chordae. This reproducible and safe technique may considerably simplify the difficult repair of chordal abnormalities.     

Mitral valve repair for broad, asymmetrical prolapse in the posterior mitral leaflet

We designed a mitral valve repair and successfully performed this repair for a case of broad, asymmetrical prolapse in the middle scallop of the posterior mitral leaflet. The repair procedure consists of making a fan-shaped leaflet by resecting the prolapsed portion in a trapezoid shape with detachment of the leaflet along the annulus and leaflet reapproximation by rotating this fan-shaped leaflet. This technique can utilize more leaflet tissue for filling the gap made by leaflet resection than the quadrangular resection and suture technique. As a result, it helps reduce tension on the suture lines, avoids the need for extensive annular plication, and also avoids leaflet distortion while making it easier to adjust the height of the leaflets that should be reapproximated. The essence of this mitral valve repair exists in the “resecting line of the leaflet,” which has not yet been reported.     

Artificial chordae

Expanded polytetrafluoroethylene sutures have been used for replacement of chordae tendineae since 1985. They have been used for correction of prolapse of mitral and tricuspid valve leaflets as well as for resuspension of the papillary muscles during mitral valve replacement when the native chordae cannot be preserved to maintain continuity between the mitral annulus and papillary muscles. The sutures used were 5CV Gore-Tex for replacement of the chordae tendineae of the anterior leaflet and 6CV for the posterior leaflet and commissural areas of the mitral valve. Initially one suture was used to create two artificial chordae, but as experience increased, the technique was modified and multiple pairs of artificial chordae were created with a single suture by passing successively through the fibrous portions of the a papillary muscle and the free margin of the prolapsing segment of leaflet, and tying the tends together on the papillary muscle head. This technique creates artificial chordae that are interdependent and their lengths are self-adjusting when pressure is exerted on the leaflets. From 1985 to 1998, 288 patients had artificial chordae used during mitral valve repair for degenerative disease of the mitral valve. Prolapse of both leaflets was present in 51% of patients, isolated prolapse of the anterior leaflet in 28%, and posterior leaflet in 21%. The mean follow-up was 4.8 +/- 3.0 years and was complete. At 10 years, the freedom from mitral regurgitation >2+ was 88 +/- 6% and the freedom from reoperation was 92 +/- 2%. Failures of repair were unrelated to the artificial chordae. Gore-Tex sutures are an excellent material to replace chordae tendineae, appear to be free of adverse effects, and have become a valuable adjunct to the surgical armamentarium to treat mitral and tricuspid valve disease.     

Mitral valve repair with artificial chordal creation

To achieve optimal long-term result of mitral valve repair, artificial chordae creation has got to be an important technique. Artificial chordae creation can preserve leaflet motion of the posterior mitral leaflet and soft coaptation area. Loop technique is suitable technique for creation of multiple artificial chordae, especially in minimally invasive minithoracotomy setting. Loop-in-loop technique is a new technique to realize easy adjusting of the length of the neochordae using slippery Gore-Tex suture. Loop-in-loop technique helps surgeons to afford variety of mitral valve repair techniques and manage complex mitral valve pathologies.     

Replacement of Chordae Tendineae with Expanded Polytetrafluoroethylene Sutures

One or more primary chordae tendineae of the anterior leaflet of the mitral valve was replaced with expanded polytetrafluoroethylene (PTFE) sutures in 22 patients as part of mitral valve reconstructive procedure. One patient with flail anterior leaflet of the tricuspid valve also had replacement of chordae tendineae with a PTFE suture. These patients have been followed from 2 to 48 months, mean of 17 months. Valve function has been assessed annually by Doppler echocardiography. The PTFE chordae cannot be visualized by two- dimensional echocardiography but they seem to allow the leaflet to move normally during the cardiac cycle. The function of the repaired valve in these 23 patients has remained most satisfactory during the observed interval. We believe that PTFE sutures can be used safely to replace diseased chordae tendineae of the mitral and tricuspid valves when conventional techniques of chordal repair are not possible.     

Implantation of a new mitral ring, adjustable during follow-up: a simplified technique

Mitral valve repair for ischaemic mitral incompetence has a 10% rate of failure at ten year follow-up. Progressive annular dilation could play an important role. We have implanted the enCor(SQ)(TM) mitral valve repair system. This system can be downsized during follow-up with the appropriate activation via the lead passed through the left atrium suture line, in order to restore mitral leaflet coaptation.     

The one-knot technique: a simple modification of the loop technique for mitral valve repair

We herein describe a simple method for the fine length adjustment of expanded polytetrafluoroethylene (e-PTFE) using the loop technique for mitral valve repair. The loops are temporarily anchored to the mitral leaflet with a second e-PTFE suture by tying only once (one-knot technique). This anchor suture can be easily removed and repositioned if necessary. We believe that this simple technique allows for the more precise and reproducible repair of mitral valve prolapse.     

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.     

Mitral valve repair for a broad prolapse in the high posterior leaflet

We report a mitral valve repair for a broad prolapse in the high posterior leaflet. Prolapse in the high redundant posterior leaflet with elongation of the chordae had caused the severe mitral valve regurgitation in a 45-year-old man. At operation, the prolapsed portion of the middle scallop was quadrangularly resected in 22 mm wide and 17 mm high. We combined the sliding leaflet technique with the posterior leaflet folding plasty to reduce the height of the posterior leaflet and to lessen the degree of mitral annular plication. Mitral valve regurgitation disappeared after the operation. No left ventricular outflow obstruction associated with systolic anterior motion and no injury to the left circumflex artery were confirmed. These procedures after a broad resection of the high posterior leaflet could successfully prevent systolic anterior motion and injury to the left circumflex artery, and reduce the stress on the suture line of the leaflet.     

Surgical management of severe truncal insufficiency: experience with truncal valve remodeling techniques

BACKGROUND: Truncal valve insufficiency has been a significant short- and long-term risk factor for repair of truncus arteriosus. Recent reports have documented the virtues of truncal valve repair. The purpose of this report is to review our experience with truncal valve repair and illustrate our techniques. METHODS: Between 1995 and 2000, 8 patients had interventions for severe truncal valve insufficiency at primary repair (3 patients) or in conjunction with conduit replacement (5 patients). One neonate had truncal valve replacement at initial repair early in the experience. The other 7 patients had truncal valve repair, 3 by valvar suture techniques. The remaining 4 patients had leaflet excision and annular remodeling in 3 (coronary reimplantation was required in 2) and commissure resuspension in 1 patient. RESULTS: Trivial to mild truncal valve insufficiency is present in the patients who had leaflet excision and annular remodeling (n = 3) and commissure resuspension (n = 1). Of the 3 patients who had valvar suture truncal valve repair, there was one death and 2 patients required acute valve replacement. The 7 survivors are doing well 1 month to 6 years postoperatively. CONCLUSIONS: Truncal valve repair by valvar suture techniques has not been successful in our practice. Truncal valve remodeling by leaflet excision and reduction annuloplasty is an effective method for truncal valve repair. When leaflet excision of a coronary sinus of Valsalva is required, coronary artery translocation can be accomplished.     

Long-term results of mitral valve repair for non-rheumatic mitral regurgitation

The durability of mitral valve repaired with reconstructive techniques is variable. If the durability continues to be good, mitral valve repair may be the procedure of choice in many patients with mitral regurgitation. Between December 1970 and June 1993, 54 patients had mitral valve repair for non-rheumatic mitral regurgitation. There were 38 men and 16 women with a mean age of 46.8 (range 19–68) years. The pathology which required surgical treatment was torn chordae in 38 patients, elongation of the chordae in five, valve prolapse without elongation or rupture of the chordae in six, infective endocarditis in three, and annular dilatation in two. Forty-four patients had triangular or quadrangular resection of the mitral leaflet, and seven had annuloplasty alone. Choral reconstruction was performed on three patients. There were no operative deaths. Five patients (9%) died late after operation. The actuarial survival rate and the valve-related death-free rate at 10 years were 83.9% and 90.0%, respectively. Seven patients (13%) required reoperation. Freedom from reoperation at 10 years was 84.5%. Improper evaluation of residual regurgitation during operation and suture dehiscence were the principal causes of reoperation. It was concluded that mitral valve repair for non-rheumatic mitral regurgitation showed low operative mortality and stable long-term results. It is suggested that intraoperative transoesophageal colour Doppler echocardiography provides accurate assessment of mitral valve competence and may be helpful in reducing the need for reoperation.     

Valvuloplasty with glutaraldehyde-treated autologous pericardium in patients with complex mitral valve pathology

BACKGROUND: Severe mitral regurgitation associated with complex mitral valve disease often precludes successful surgical repair. The feasibility and the results of valvuloplasty with glutaraldehyde-treated autologous pericardium remain largely unknown. METHODS: The cases of 63 patients who underwent operation within an 11-year period were studied. A pretreated autologous pericardial patch was used for leaflet extension plasty, for paracommissural plasty, as a substitute for part of the leaflet, and for reimplantation of ruptured papillary muscles to eliminate severe mitral regurgitation. Patients with a severely calcified annulus after en bloc decalcification had straddling endoventricular pericardial patch annuloplasty for reconstruction of the affected atrioventricular groove. Chordal replacement with a strip of pericardium was chosen if no suitable chordae were available. Pericardium-reinforced suture annuloplasty was used in patients with acute endocarditis resistant to medical therapy. Associated valvuloplasty procedures with Carpentier techniques were also employed. RESULTS: There were no operative deaths in this series. At a mean follow-up of 61.1 months (range, 4 to 132 months), mitral regurgitation was absent or trivial in 92.1% of patients by echocardiography. Freedom from reoperation was 95.2% at 1 year and 5 years. Thromboembolic events have not been detected. Thirty percent of patients returned to sinus rhythm. Two patients required valve replacement. CONCLUSIONS: Our beneficial results indicate that glutaraldehyde-treated autologous pericardium is suitable for valvuloplasty. It provides durable and predictable repair of valves that might otherwise need to be replaced because of the complex mitral valve disease. The technique is reliable, allows further efficacious repair possibilities, and improves postoperative outcomes. Whether it can prevent late deterioration and calcification requires more investigation.     

右腋下小切口二尖瓣成形术68例

目的探讨经右腋下小切口行二尖瓣成形术的临床效果。方法回顾性分析2003年1月～2011年12月经右腋下5～10 cm小切口行二尖瓣成形术68例的资料。二尖瓣成形方法包括瓣叶裂隙修补6例,瓣叶部分切除28例,交界成形12例,双孔成形10例,人工腱索6例,腱索缩短3例,瓣叶心包补片修补3例;68例中人工瓣环植入38例。结果 68例手术均顺利完成,无严重并发症发生,无手术死亡。术后1周复查超声心动图,二尖瓣无明显反流或仅微量反流52例,轻度反流16例。随访65例,随访时间3个月～8年,其中〉3年32例,2例复发二尖瓣重度关闭不全,经胸骨正中切口行二尖瓣置换手术。其余患者二尖瓣反流均在中度以下。结论右腋下小切口二尖瓣成形术创伤小,出血少,临床效果良好,并且切口位置隐蔽,美容效果好。     

Replacement of Mitral Valve Posterior Chordae Tendineae with Expanded Polytetrafluoroethylene Suture: A Finite Element Study

A bstract Background and Aims : Expanded polytetrafluoroethylene (ePTFE) suture has been used clinically for replacement of ruptured mitral valve chordae tendineae. The purpose of this study was to assess mitral valve function after posterior chordal replacement with ePTFE suture. Methods : A three-dimensional finite element computer model of the mitral valve was used, which incorporated geometry, regional tissue thickness, collagen fiber orientation, and anisotropic material properties for the leaflets, interface, and chordae tendineae. To simulate chordal rupture, four marginal and four basal chordae were removed from the posterior leaflet. Chordal replacement was simulated using two elements with the physical and material properties of 2–0 ePTFE suture. Systolic loading pressures were applied. Results : The chordal rupture model demonstrated posterior leaflet prolapse, abnormal stress concentrations, potential regurgitation, and elevated chordal stress. Conversely, the chordal replacement model corrected the prolapse and returned chordal stress to normal levels. However, stress concentrations were shown at suture attachment points. Conclusions : This integrated mitral valve finite element model provides a tool to investigate the performance of the valve system. In this study, we have shown that 2–0 ePTFE suture replacement of ruptured posterior chordae tendineae returns the valve to a near normal state, in terms of leaflet stress and coaptation, and chordal stresses.     

Mitral valve repair by replacement of chordae tendineae with polytetrafluoroethylene sutures

Expanded polytetrafluoroethylene sutures have been used for replacement of diseased chordae tendineae during reconstructive procedures on the mitral valve in 43 patients. There were 28 men and 15 women whose mean age was 55 years, range 21 to 76. Three fourths of the patients were in New York Heart Association class III or IV. Replacement of primary chordae tendineae of the anterior leaflet was performed with 4-0 or 5-0 polytetrafluoroethylene sutures. A double-armed suture was passed twice through the fibrous portion of the papillary muscle head and tied down. Each arm of the suture was brought up to the free margin of the leaflet and passed through the area where the native chorda was attached. After the lengths of the two arms were adjusted, the ends were tied together on the ventricular side of the leaflet. Thirty patients had degenerative disease of the mitral valve; the incompetence was due to prolapse of the anterior leaflet in 14 patients and prolapse of the anterior and posterior leaflets in 16. Eleven patients had rheumatic mitral valve disease: four had stenosis, three had regurgitation, and four had mixed lesions. Two patients had ischemic mitral regurgitation caused by rupture of a papillary muscle head. There were no operative deaths. Patients have been followed up from 5 to 61 months, mean 13. Doppler echocardiographic studies were performed at regular intervals after the operation and revealed normal mitral valve function in most patients There were two failures that necessitated mitral valve replacement: one because of acute mitral regurgitation and the other because of hemolysis. There have been two late deaths, neither one valve related. Replacement of chordae tendineae with polytetrafluoroethylene sutures is simple and allows for reconstruction of the mitral valve in many patients who would otherwise require mitral valve replacement. Because our patients have been followed up for a limited time, the long-term results of this procedure remain unknown.     

Mitral valve reconstruction: long-term results of triangular resection for degenerative prolapse

Objectives. Surgical treatment of a prolapsed anterior leaflet of the mitral valve is relatively difficult and controversial compared with management of a prolapsed posterior leaflet. The aim of this study was to assess the long-term results of mitral valve repair, focusing on triangular resection of the anterior leaflet. Methods. Between October 1991 and December 2006, surgical treatment for a prolapsed anterior leaflet was performed in 57 patients with degenerative mitral valve disease, including 49 patients who had anterior leaflet resection. Patients with mitral stenosis, ischemic mitral regurgitation, and congenital valvular disease were excluded. The mean age of the patients was 51.7 ± 15.9 years, and the mean follow-up period was 6.2 ± 3.8 years. Results. The overall actuarial survival rate and noreoperation rate at 10 years were 91.7% ± 4.1% and 92.3% ± 3.7%, respectively. Reoperation was performed in 2 (4%) of 49 patients who had anterior leaflet resection. All patients survived after reoperation, which involved mitral valve replacement. Postoperative echocardiographic studies showed that the mitral valve area was significantly smaller after repair in patients with anterior leaflet resection, but the area was still large enough for a functional valve. Among the 57 patients, 42 had no mitral regurgitation, whereas it was mild in 7 patients and moderate in 3 patients. Conclusion. Triangular resection of a prolapsed anterior leaflet of the mitral valve provides durable and reliable long-term results.     

Surgical treatment of active infective mitral valve endocarditis.

Although infective endocarditis is primarily treated conservatively with antimicrobial therapy, early surgical intervention is often mandatory when various complications arise. These include intractable heart failure, persistent uncontrollable infection, large mobile vegetations, peripheral embolism and prosthetic valve endocarditis. Optimal timing of surgical intervention in patients with infected heart valves results in reduced early and late mortality. In the context of healed infective endocarditis, mitral regurgitation is treated with mitral valve repair, which produces long-term results similar to those seen for treatment of degenerative mitral regurgitation. Mitral valve repair should also be considered for patients with mitral regurgitation due to active infective endocarditis. Superficial infection without valve destruction is the best candidate for valve repair. Discrete vegetations on the valve leaflets are excised along with underlying leaflet tissue (vegetectomy). Although valve lesions can be repaired by standard techniques, particular care (e.g., reinforcement with a pericardial patch) should be taken to avoid excess tension on the suture line. The feasibility of valve repair depends on the extent of tissue destruction. Large defects of the anterior leaflet, due to transmural infection or lesions that encompass greater than one-third of the entire posterior leaflet with annular abscess, are not amenable to repair. Also, the involvement of the aortic valve frequently necessitates valve replacement. Further, unstable preoperative hemodynamics leads to the decision to perform valve replacement immediately rather than complicate valve repair in an attempt to avoid prolonged operation time for life salvage. In the context of the feasibility of valve repair, timely surgical intervention and precise repair technique are essential.