Mitral valve annuloplasty for degenerative disease: assessment of four different techniques

BACKGROUND AND AIM OF THE STUDY: Mitral valve repair (MVR) is the treatment of choice in patients with degenerative valve disease. However, controversy persists as to whether mitral valve annuloplasty should always be included as part of the reconstructive procedure. METHODS: The records of 62 consecutive patients undergoing MVR for degenerative disease between January 1994 and December 1996 were reviewed. Four different annuloplasty techniques were associated with various MVR procedures: local posterior annuloplasty (group 1, n = 10), rigid Carpentier ring (group 2, n = 20), Duran ring (group 3, n = 17), and posterior annular plication with autologous pericardium (group 4, n = 15). The four patient groups were similar in terms of preoperative clinical and echocardiographic characteristics. Serial clinical and echocardiographic follow up was performed to assess functional status and stability of repair. RESULTS: There were no early or late deaths. Mean follow up in the entire patient series was 31 +/- 12 months. One patient in group 2 required reoperation 14 months after MVR. In all groups there was a significant improvement in NYHA functional class (from 2.7 +/- 0.6 to 0.9 +/- 0.5, p <0.001), with a reduction of left ventricular end-diastolic and end-systolic volumes (154 +/- 50 ml to 105 +/- 33 ml, p <0.001; and 64 +/- 23 ml to 52 +/- 22 ml, p <0.001). In patients of groups 2, 3 and 4, residual mitral incompetence at follow up (0.8 +/- 0.9 in group 2, 0.8 +/- 0.7 in group 3, and 0.2 +/- 0.6 in group 4) was not significantly different from discharge. However, in group 1, a higher degree of residual mitral regurgitation was present at discharge (0.9 +/- 0.6) with a trend to progress at follow up (1.6 +/- 0.5). CONCLUSION: In patients with degenerative mitral valve disease, MVR provides clinical and functional improvement. Techniques of stabilization of the entire posterior mitral annulus achieve better early and medium-term results, and should be always considered as part of MVR. Autologous pericardium appears to be an excellent annuloplasty material, though its apparent superiority over synthetic rings must be confirmed at longer follow up.     

Mitral valve repair for mitral regurgitation

We analyzed the results of mitral valve repair in 81 consecutive patients with severe mitral regurgitation. Of these patients, 66.6% had myxomatous degeneration, 11% ischemic disease, 8% chordal rupture, 5% congenital disease, and 3.7% endocarditis. Repair could not be achieved in five patients, and valve replacement was necessary. Six died during surgery (mortality 7%). During follow-up (mean 30 [8] months), there was one death due to refractory ischemic heart failure and mitral regurgitation (>or= 2/4) was observed in 11 patients. A good result (i.e., survival without a prosthesis, major complications, or mitral regurgitation >1/4) was obtained in 78% of patients with myxomatous degeneration versus 48% of those with other etiologies (P=.023). A good result was obtained more frequently in cases of isolated posterior cusp degeneration than in those involving degeneration of both cusps (85% vs 70%; P=.03).     

Mitral valve repair today

Valve reconstruction, whenever technically feasible, is currently the treatment of choice for mitral valve regurgitation. Preoperative transesophageal echocardiography discloses the precise location and extent of these lesions, making it possible for the surgeon to determine the repairability of the valve and to devise a roadmap for the most appropriate surgical maneuvers. Today, the aim of surgery should not be limited to abolishing regurgitation, but should also comprise restoration of the normal valve geometry in order to ensure durability of the repair. This geometric redress involves a) leaflet enlargement or reduction, b) replacement of all ruptured, elongated or attenuated chords with Goretex sutures, and c) annuloplasty with a flexible, complete ring that prevents distension even in the intertrigonal area, maintains the saddle shape of the annulus and reduces the dilated anteroposterior diameter of the annulus. These techniques have made repair rates approaching 100% possible in patients with degenerative valve diseases. For functional ischemic regurgitation, treatment currently consists of reduction annuloplasty with a small complete ring performed at the time of revascularization. However, despite the improvements seen in these patients, late recurrence of insufficiency occurs in about 30% of them. Recent evidence that the mechanism of recurrence is the apical and lateral displacement of the papillary muscles suggests that in addition to annuloplasty, surgical approximation of the papillary muscles may be necessary.     

Mitral valve repair with aortic valve replacement in rheumatic heart disease

From 1992 to 2001, 609 patients with rheumatic heart disease underwent aortic valve replacement with either mitral valve repair (n = 201) or mitral valve replacement (n = 408). Follow-up extended to 10 years. Thirty-day mortality was 1.4% for mitral valve repair and 0.7% for mitral valve replacement (p = 0.4). Survival at 9 years was 96.5 +/- 1.4% after mitral valve repair and 89.7 +/- 7.8% after mitral valve replacement (p = 0.73). Freedom from major bleeding at 9 years was 94.8 +/- 2.4% after mitral valve repair and 81 +/- 7.2% after mitral valve replacement (p = 0.03). Freedom from other valve-related complications and from mitral valve re-operation was similar for the two groups. This study showed that in patients with rheumatic heart disease the results of mitral valve repair with aortic valve replacement were comparable to those of double valve replacement. Major bleeding was less frequent after mitral valve repair with aortic valve replacement. Therefore, whenever feasible, mitral valve repair should be attempted in patients with rheumatic heart disease who need concomitant aortic valve replacement.     

Mitral stenosis after mitral valve repair using the duran flexible annuloplasty ring for degenerative mitral regurgitation

The case is presented of a 47-year-old woman who had undergone mitral valve repair using the Duran annuloplasty ring four years earlier, and who was diagnosed with mitral stenosis owing to fibrous tissue overgrowth. In this patient, dense whitish fibrous tissue covered the annuloplasty ring and extended onto both leaflets of the mitral valve, narrowing its orifice and rendering the leaflets stiff and immobile. The pannus covering the mitral valve could not be stripped off without damaging the leaflets, making mitral valve replacement necessary. Mitral valve replacement with a St. Jude Medical mechanical heart valve prosthesis was successfully performed, and no major perioperative complications were encountered.     

非风湿性二尖瓣关闭不全的外科治疗

目的 评价二尖瓣瓣膜成形术(MVP)对非风湿性二尖瓣关闭不全的疗效.方法 2001年1月至2005年12月我院非风湿二尖瓣关闭不全心脏患者23例接受手术治疗,男性13例,女性10例,年龄16～71(49.4±5.7)岁.非风湿性二尖瓣关闭不全病因中,其中先天性5例,退行性改变12例,缺血性改变4例,感染性病变2例.术前超声心动图示二尖瓣均为大量返流,术前患者心功能Ⅲ级19例,Ⅳ级4例.瓣环成形13例,腱索短缩3例,裂修补1例,腱索转移1例,后瓣环成形 裂修补4例,部分瓣膜切除 裂修补1例.同期冠状动脉搭桥术5例,主动脉瓣膜置换术3例.结果 早期死亡率4.3%(1例),术后超声心动图示无或少量二尖瓣反流13例,少量到中量反流8例,大量反流1例.随访6～60个月(平均27个月),出院后2例患者死亡,再次手术1例.存活20例,心功能Ⅰ～Ⅱ级.结论 应用二尖瓣膜成形术治疗非风湿性二尖瓣关闭不全是可行的,可以取得良好的效果,外科技术值得进一步推广.     

Mitral valve repair for nonrheumatic mitral regurgitation

BACKGROUND: We studied the results of mitral valve repair in patients with severe mitral regurgitation of nonrheumatic etiology. METHODS AND RESULTS: Between January 1988 and April 2002, 116 patients, of which 59 were male and 57 female, with severe mitral regurgitation of nonrheumatic etiology, underwent mitral valve repair using a variety of techniques. Their mean age was 26.4 years (range 2-67 years). The cause of mitral regurgitation was congenital in 56 patients, myxomatous in 44, infective endocarditis in 7, and ischemic in 9. Ninety patients were in preoperative New York Heart Association class III, and 26 in class IV. Reparative procedures included posterior teflon felt collar annuloplasty (modified Cooley's) in 80 patients, chordal shortening in 37, cusp excision in 34, cleft closure in 8, chordal transfer in 6, and neochordae in 3. The early mortality was 3.4% (4 patients). Follow-up ranged from 1 to 167 months (mean 47 months), and was 95% complete. There were 2 late deaths (1.7%). Six patients (5.2%) underwent reoperation for severe mitral regurgitation post-repair. Of the remaining 104 patients, 90 (86.5%) had no or trivial mitral regurgitation at the last follow-up. Actuarial, reoperation-free, and event-free survival at 130 months was 93%+/-3.6%, 89.9%+/-6%, and 69.7%+/-13.7%, respectively. Ninety-two patients (88.5%) were in New York Heart Association class I at the last follow-up. CONCLUSIONS: Mitral valve repair in nonrheumatic mitral regurgitation patients provides satisfactory results with current surgical techniques, and is the preferred option in this subset of patients.     

Mitral valve repair versus mitral valve replacement

Zusammenfassung In den letzten 40 Jahren hat die Mitralklappenchirurgie einen grundlegenden Wandel erfahren. Der initialen Begeisterung nach der Einführung von Klappenprothesen in den 60er Jahren folgte eine Renaissance der Rekonstruktion der Mitralklappe mit der Vorstellung der Ringannuloplastie-Technik in den 70er Jahren. Die Rekonstruktion der Mitralklappe erhält die Integrität der subvalvluären Strukturen, die eine entscheidende Rolle für die linksventrikuläre Funktion spielen. Große Studien, die sowohl Früh- als auch Langzeitergebnisse nach Mitralklappenrekonstruktionen gegenüber prothetischem Klappenersatz betrachteten, zeigten eine geringere Operationsmortalität sowie eine deutlich höhere Langzeitüberlebensrate bei Patienten nach Mitralklappenrekonstruktion. Weiterhin sind spezifische Probleme, wie Thromboembolien oder Endokarditis, die bei Klappenersatzverfahren auftreten können, zu nennen. In Anbetracht dieser Tatsachen sind klappenerhaltende Rekonstruktionstechniken von Vorteil. Jedoch ist die Entscheidung für eine Mitralklappenrekonstruktion von unterschiedlichen Faktoren abhängig, wie der Ätiologie der Mitralklappenerkrankung und der daraus folgenden Pathomorphologie der Klappe, sowie patientenabhängigen Einflüssen, wie z.B. Alter oder Kontraindikationen für eine Antikoagulationstherapie und nicht zuletzt der Erfahrung des Chirurgen. Somit ist der Prozess der Wahl eines geeigneten Operationsverfahrens sehr komplex und individuell von jedem Patienten abhängig zu machen. Sowohl Studiendaten als auch Datenbanken großer Patientenkollektive reflektieren die Vorteile der Mitralklappenrekonstruktion mit einem Rekonstruktionsanteil von bis zu 75 % in der gesamten Mitralklappenchirurgie. In den letzten 5 Jahren wurde der videoassistierte Zugang zur Mitralklappe über eine rechtslaterale Minithorakotomie zu einem etablierten Verfahren entwickelt. Dieser minimalinvasive Zugang erlaubt sowohl komplexe Rekonstruktions- als auch Klappenersatzverfahren unter anderem mit gerüstfreien Bioprothesen. Zusätzliche chirurgische Verfahren, wie die linksatriale Hochfrequenzablation zur Herstellung eines Sinusrhythmus bei Patienten mit Vorhofflimmern, verbessern das Operationsergebnis nach Mitralklappenchirurgie sowohl hinsichtlich der kardialen Funktion als auch der Lebensqualität für den Patienten deutlich und können ebenfalls über den minimalinvasiven Zugang durchgeführt werden. Summary Over the past 40 years mitral valve surgery has changed dramatically. After initial enthusiasm with the introduction of valve prostheses in the 1960s, a renewed interest in repair techniques began in the 1970s with the introduction of annuloplasty rings. These repair techniques revealed that the integrity of the subvalvular apparatus plays an important role in left ventricular function. When considering the major series comparing early and late results of mitral valve repair versus prosthetic mitral valve replacement, operative mortality rate is lower for patients with mitral valve repair. Long-term results also show a superior survival rate after mitral valve reconstruction. In addition, several problems can occur with the prosthetic valve, such as thromboembolism and endocarditis. All of these factors favor valve repair over replacement. The success of mitral valve repair depends on many factors: etiology of the mitral valve disease and the resultant pathomorphology of the valve, patient's circumstances such as age or contraindication for anticoagulation, and the experience of the surgeon. The decision whether to repair or replace the mitral valve depends on these factors. Data in the literature and in large collective databases reflect the advantages of mitral valve repair, with over 75 % of current mitral valve surgeries being repairs. In the past 5 years the exposure of the mitral valve through a right lateral minithoracotomy using video assistance has developed into a widespread technique. This approach allows complex mitral valve repair as well as mitral valve replacement even with biological stentless prostheses, with decreased morbidity. The addition of radiofrequency ablation for restoration of sinus rhythm enhances the outcome after mitral valve surgery, and can also be easily performed through a minithoracotomy technique.     

Mitral valve repair versus replacement

When considering all the major series comparing the early and late results of mitral valve repair versus prosthetic or bioprosthetic mitral valve replacement, the operative mortality rate is slightly lower for patients undergoing valve reconstruction. Late survival is also superior after valve repair. Although these modest differences may be related to patient selection bias, a lower rate of thromboembolic and endocarditis-related complications and improved LV function remain as rather compelling factors favoring valve repair. The durability of valve repair is comparable to valve replacement in terms of reoperation rate, except in cases of rheumatic valve abnormality (in which reoperation rates are higher after valvuloplasty). Definitive, objective evidence favoring mitral valve repair is lacking given the short period of followup in all studies and absence of controlled, randomized clinical trials. The success of mitral valve reconstruction relies heavily on the experience and technical expertise of the surgeon. The wide variability in observed survival rates, however, is unlikely to be due to differences in surgical skill between experienced groups; it more likely represents the results of differing criteria for mitral valve repair, various followup intervals, and comparisons between distinctly different cohorts. Although a prospective randomized trial would be ideal to compare the results of mitral valve reconstruction versus mitral valve replacement for patients with mitral valve regurgitation, it is unlikely and unrealistic that such a study will ever be conducted. The universal applicability of the results of such a study would also be dubious, given the widely varying extent of surgical expertise with mitral valve repair. Furthermore, not all types of mitral regurgitation are amendable to reconstruction short of using patch techniques (usually autologous pericardium treated with glutaraldehyde) or resorting to artificial chordae (e.g., extensive leaflet destruction from rheumatic changes or infective endocarditis, and substantial anterior leaflet redundancy). In cases in which mitral valve replacement is necessary, preservation of the mitral subvalvular apparatus promises to be an important concept to preserve optimal systolic LV function postoperatively.     

二尖瓣成形治疗小儿二尖瓣关闭不全

目的 总结小儿二尖瓣关闭不全外科矫治经验。方法 回顾近12年我院收治75例小儿二尖瓣关闭不全患,其中男31例,女44例,年龄1．5－12岁,平均7．1岁。单纯二尖瓣关闭不全8例,合并其它心血管畸形67例。二尖瓣关闭不全轻度7例,中度47例,重度21例。二尖瓣脱垂24例,瓣叶裂38例,瓣叶发育不良2例,单纯二尖瓣环扩大11例。手术在中低温体外循环心内直视下进行,行腱索缩短13例（含多根腱索缩短4例）,乳头肌缩短1例,腱索移植3例,瓣叶修复41例,瓣环成形25例,二尖瓣置换2例。同时矫正合并心血管畸形。结果 全组无手术死亡。完全矫正二尖瓣关闭不全54例（71．2％）,残留少量反流17例（23．3％）,中度反流4例（5．5％）。术后随访1．5－13年（平均7．8年）,1例术后4．5年因急性左心衰再次行人工瓣置换术,1例合并严重肺动脉高血压术后5年死于右心衰竭,1例人工瓣置换术后失访。其余患发育良好,心功能均恢复正常。结论 二尖瓣成形术治疗小儿二尖瓣关闭不全可取得良好的效果。     

Mitral valve repair for significant mitral insufficiency.

There has been skepticism since the early days of open heart surgery that good long-term or even short-term results were possible with repair of pure mitral insufficiency. The authors report 145 patients in whom a markedly insufficient mitral valve was repaired 6 months to 17 years previously and another 55 patients in whom repair of the insufficient mitral valve was performed along with myocardial revascularization from 6 months to 7 years previously. Comparative data with other published work reveals superior results with repair than with replacement with Starr-Edwards and Hancock glutaraldehyde-treated porcine valves and with far less emboli. Conservatism is urged in operating upon patients with mitral insufficiency. Repair of the valve rather than replacement is stressed for those patients requiring surgery.     

Mitral valve repair in heart failure

Mitral regurgitation (MR) is a frequent complication of end-stage heart failure. Historically, these patients were either managed medically or with mitral valve replacement, both associated with poor outcomes. Mitral valve repair via an 'undersized' annuloplasty repair is safe and effectively corrects MR in heart-failure patients. All of the observed changes contribute to reverse remodeling and restoration of the normal left-ventricular geometric relationship. Mitral valve repair offers a new strategy for patients with MR and end-stage heart failure.     

Mitral valve replacement and tricuspid valve repair in a patient with sickle cell disease

Sickle cell disease is a rare entity for the European cardiac surgeon to encounter. Low oxygen tension, acidosis and hypothermia may induce sickling and pose a great risk in this population during open heart surgery. We report the management of a 57-year-old Greek woman with homozygous sickle cell disease and rheumatoid arthritis, who underwent preoperative partial exchange transfusion and subsequent mitral valve replacement and tricuspid valve repair at normothermia.