Leaflet resection for the degenerative mitral valve regurgitation; early/long-term assessment

Leaflet resection for posterior leaflet prolapse has been a standard repair procedure with good longterm durability. The aim of this study was to review our experience of mitral valve repair, in which resection of the anterior and/or posterior leaflets was performed. Between October 1991 and December 2010, 172 patients with degenerative mitral valve regurgitation underwent mitral valve reconstruction,including 98 patients with the posterior leaflet prolapse, 47 patients with the anterior leaflet prolapse, 17 patients with both leaflets and 10 patients with the commissure prolapse. Most patients in this study were supposed to be caused by fibroelastic deficiency and we have not experienced systolic anterior motion after repair. The mean follow-up period was 8.7 ± 5.5 years. The freedom from reoperation rates at 15 years in 88.7 ± 5.3% of the anterior leaflet procedure, 96.6 ± 2.5% of the posterior leaflet, and 100% of both leaflets. The results of resection of a diseased prolapsed mitral leaflet have been promising so far. However, reoperation was required in 7 patients (4.1%) and reoperation rate was higher in patients with anterior prolapse and longer follow-up will evaluate precisely be benefit.     

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.     

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.     

Unusual mitral valve abnormalities complicating surgical repair of endocardial cushion defects

A review of 155 cases of surgically repaired endocardial cushion defects revealed 16 patients (10%) with additional unusual mitral valve abnormalities that complicated the surgical procedure. Eight patients had accessory mitral valve tissue that connected the anterior and posterior leaflets to form a double-orifice valve (Group I). In four (50%), the lesion was associated with intermediate atrioventricular canal and small left ventricle; all four died following repair. In the other four, it was associated with ostium primum defect; all survived and are well. A single papillary muscle in the left ventricle was present in six patients (Group II). Two had intermediate atrioventricular canal and both died postoperatively. The other four had complete endocardial cushion defect and three are well following the operation. Perforation of the valve leaflets was present in two patients with ostium primum (Group III). Both patients are well postoperatively. Modification of the surgical technique is required to effect satisfactory repair. The bridge connecting the posterior and anterior leaflets of the mitral valve should be left undisturbed. Otherwise, severe regurgitation may result. In patients with single papillary muscle and complete atrioventricular canal, repair may be accomplished by borrowing from the tricuspid portion of the anterior leaflet, rotating that part posteriorly, and partially closing the cleft. Small perforations of the mitral leaflet do not require closure and do not result in regurgitation. Echocardiographic and angiographic delineation of these abnormalities and thorough intraoperative exploration are important in avoiding pitfalls at the time of repair.     

改良腱索转移法治疗二尖瓣前叶脱垂(附16例临床分析)

目的 介绍一种操作简单、效果可靠的矫治二尖瓣前叶脱垂的手术方法.方法 2002年1月至2008年5月,应用"缘对缘"技术基础上的腱索转移法治疗二尖瓣前叶脱垂共16例,其中腱索断裂12例,腱索延长4例.超声心动图均显示二尖瓣前叶脱垂致重度关闭不全,平均反流面积(14.76±3.28)cm2,左心室射血分数33%～69%.按照NYNA分级,术前心功能Ⅲ级5例,Ⅳ级11例.手术首先行脱垂部位前瓣与相应部位后瓣的"缘对缘"缝合,矩形切下缝合处的后瓣,连同相应的腱索、乳头肌,转移至前瓣.再行后瓣成形,完成瓣膜成形手术.所有病人出院前和随访时再次行超声心动图检查.结果 手术无死亡,除1例因为术后第3天出现二尖瓣前叶穿孔再次行二尖瓣置换手术外,其余15例手术病人均顺利康复出院.术后远期随访无死亡,心功能全部恢复至Ⅰ级.复查超声心动图二尖瓣瓣口面积3.3-4.8 cm2,平均(3.78±0.52)cm2,均无明显反流,反流面积(0.45±0.22)cm2,左房、左室明显缩小[(左房径:术前(48.26±11.12),mm,术后(37.57±9.56)mm,P=0.028;左窜舒张末径术前(61.43±8.24)mm,术后(42.35±10.79)mm,P=O.008].结论 "缘对缘"技术基础上的腱索转移法治疗二尖瓣前叶脱垂,操作简单,可以取得良好的成形效果.     

Leaflet folding plasty for mitral valve repair

Objectives: Leaflet folding plasty was introduced for avoiding systolic anterior motion and coronary artery injury after mitral valve repair. We report the application and early outcome of this technique for mitral valve regurgitation. Methods: From January 1997 to January 2004,16 patients with mitral valve regurgitation were operated on using leaflet folding plasty. The group comprised 9 men and 7 women, with a mean age of 61.6 years. There were 15 patients with degenerative and 1 with ischemic mitral valve disease. The causes of mitral regurgitation were posterior mitral leaflet prolapse in 11 patients and commissural prolapse in 5 patients. Results: Mitral valve reconstruction could be performed in all patients. There were no perioperative deaths. Postoperative mitral regurgitation fell to 0.13±0.52 compared with 3.6±0.51 preoperatively. Systolic anterior leaflet motion was not observed in any patients after the procedure. The mean follow-up period was 22 months. There were no late deaths and reoperation was not required during follow-up. Conclusions: Early outcome of leaflet folding plasty for mitral valve repair was satisfactory. This technique may have advantages to accomplish mitral valve repair safely in patients with mitral regurgitation due to posterior or commissural prolapse.     

Neochordal repair of a double orifice mitral valve

Native double-orifice mitral valve is an exceedingly rare valvular abnormality. A 77-year-old patient was referred for a severe mitral regurgitation, and a double-orifice mitral valve with a central fibrous bridge was unexpectedly found. A flail anterior leaflet with 2 ruptured chordae was observed on the anterolateral mitral valve orifice, the leaflets on the posterior valve orifice were normally thin. Mitral valve repair was successfully performed with replacement of the 2 torn chordae by two 4/0 expanded polytetrafluoroethylene neochordae. We accordingly suggest that current mitral valve repair techniques remained a valuable option, even on central bridge double-orifice mitral valve regurgitation.     

The double-orifice technique in mitral valve repair: a simple solution for complex problems

OBJECTIVE: The aim of this study is to report our results with the central double-orifice technique used for the treatment of complex mitral valve lesions. METHODS: The central double-orifice repair has been used in 260 patients (mean age, 56 +/- 14.3 years) over a period of 7 years. The mechanism responsible for mitral regurgitation was prolapse of both leaflets in 148 patients, prolapse of the anterior leaflet in 68, prolapse of the posterior leaflet with annular calcification or other unfavorable features in 31, and lack of leaflet coaptation for restricted motion or erosion of the free edge in 13. Degenerative disease was the cause of mitral regurgitation in 80.8% of the patients, rheumatic disease was the cause in 9.6%, endocarditis was the cause in 6.1%, and ischemic disease was the cause in 2.3%. RESULTS: Hospital mortality was 0.7%, and the overall survival at 5 years was 94.4% +/- 2.59%. Thirteen patients required a reoperation (2 early postoperatively and 11 late during the follow-up), for an overall freedom from reoperation of 90.0% +/- 3.37% at 5 years. Freedom from reoperation was lower in patients with rheumatic valve disease and in patients who did not undergo an annuloplasty procedure. CONCLUSIONS: The effectiveness and durability of the central double-orifice technique were assessed in this study. This type of repair can be a useful addition to the surgical armamentarium in mitral valve reconstruction.     

Repair of mitral regurgitation caused by prolapse of the anterior mitral leaflet

Mitral regurgitation caused by prolapse of the anterior mitral leaflet has been considered to be difficult for reconstruction. In Japan, these cases have been repaired mainly by replacement of chordae with artificil sutures. We have repaired them by Carpentier’s technique. We report a series of 9 patients with pure mitral regurgitation caused by ruptured or elongated chordae of the anterior mitral leaflet. Two of them had lesions at both anterior and posterior leaflet. All patients underwent mitral valve repair by segmental transposition of the posterior leaflet. As for associated procedures, there were ring annuloplasty with Carpenter rings (9 cases), sliding technique (8 cases) reported by Carpentier, reinforcement by transposition of secondary chordae of the posterior leaflet (6 cases), commissuroplasty (1 case), and closure of leaflet perforation. All patients survived operations and all patients except one underwent left ventriculography postoperatively. In only 2 patients, residual mitral regurgitatin classed as I/IV was observed. All patients returned home in New York Heart Association class I. Follow-up ranged from 7 to 45 months (mean follow-up 20 months). All patients were free from reoperation or thromboembolism. Although longer follow-up is necessary, this technique appears to be adequate for the repir of patients with anterior leaflet prolapse.     

Simultaneous operation of WPW syndrome combined with mitral regurgitation caused by infective endocarditis

A case of WPW syndrome combined with mitral regurgitation caused by infective endocarditis underwent surgical division of accessory pathway and mitral valve replacement preserving posterior leaflet simultaneously. A 56-years old woman suffered atrial fibrillation with pseudo VT and cardiac failure caused by mitral regurgitation. Electro-physiological study (EPS) revealed accessory pathway in postero-lateral wall in left atrium and atrio-fascicular pathway like James bundle in AV node. ECHO cardiography showed mitral valve prolapse and severe regurgitation. Accessory pathway was divided surgically and deep freeze coagulation was followed. Perforation of anterior leaflet and chordal rupture of posterior leaflet caused by infective endocarditis were repaired by annuloplasty (Kay and McGoon method) at first, but regurgitation retained moderately. After re-clamping of aorta, mitral valve was replaced with prosthesis (SJM 29 mm) preserving posterior leaflet. Postoperative examination revealed division of accessory pathway and no regurgitation of mitral prosthesis.     

后叶腱索转移治疗二尖瓣前叶脱垂

目的总结采用后叶腱索转移术治疗二尖瓣前叶脱垂的临床经验和体会,探讨二尖瓣成形术的黄金时机。方法2004年10月至2008年10月治疗二尖瓣前叶脱垂16例,超声心动图检查诊断：二尖瓣前叶脱垂、腱索断裂10例,腱索延长4例,断裂合并延长2例;A1区域脱垂3例,A2区域脱垂6例,A3区域脱垂3例,合并A1、A2区域脱垂2例,A2、A3区域脱垂2例;均采用后叶腱索转移技术,其中1例合并冠心病患者同期施行冠状动脉旁路移植术。结果无手术死亡。出院前超声心动图检查提示：有少量反流2例,微量反流6例,无反流8例。出院后华法林抗凝治疗3个月。随访16例（100％）,随访1～46个月（22．0±3．5个月）,超声心动图提示：有少量反流3例,微量反流7例,无反流6例,效果优良。心功能Ⅰ级12例,Ⅱ级4例。出院前射血分数（EF）较术前降低（53．0％±3．4％vs．65．0％±4．2％,P=0．013）,术后随访时EF与术前比较差异无统计学意义（61．0％±2．1％vs．65．0％±4．2％,P=0．110）;出院前和随访时左心室舒张期末内径较术前明显缩小（50．0±3．2mm,47．0±2．8mmvs．58．0±6．5mm,P=0．031,0．020）;随访时心功能较术前明显改善（P=0．002）。结论后叶腱索转移是治疗二尖瓣前叶脱垂的有效方法,心瓣膜成形术的最佳时期是术前EF值大于60％、左心室轻度增大、心功能在Ⅲ级以上。     

Leaflet folding plasty combined with annular plication for mitral valve repair

We describe a new technique of mitral valve repair based on two reconstructive techniques: (1) the folding leaflet method, and (2) the classic annular plication. This combination appears to be useful in cases with a large prolapsing posterior mitral leaflet with excessive leaflet height or in cases with commissural prolapse involving both the anterior and posterior leaflets.     

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 insufficiency due to ruptured chordae tendineae--clinical features, early and late results of valve replacement and repair

To evaluate the early and late results of mitral valve replacement and reconstruction for mitral insufficiency due to ruptured chordae tendineae respectively, 74 consecutive cases were analyzed. Fifty-five (74.3%) of the patients were men, and the mean age was 48 +/- 12 years old (range 16 to 76). The causes of the mitral disease were idiopathic in 50 (67.6%), rheumatic in 7 (9.4%) and infective endocarditis in 11 (14.9%) patients. In idiopathic 50 cases, 24 had mitral valve prolapse and 16 had both mitral valve prolapse and hypertension. Forty-one (55.4%) of the patients were in NYHA functional class III or IV preoperatively. Thirty (40.5%) cases underwent surgery within one year after their initial symptoms of heart failure onsets including six emergency operation cases due to uncontrollable acute lung edema. Chordae to anterior mitral leaflet were ruptured in 31 (a5, m16, p10)[41%] patients, to the posterior mitral leaflet in 45 (a4, m23, p18)[59%], and to both leaflets in one patient. Mitral valve replacement was performed in 68 patients (91.9%) and 6 patients (8.1%) underwent mitral valve repairs. Twenty cases underwent associated procedures that included tricuspid valve annuloplasty in 8, aortic valve replacement in 5 and myocardial revascularization in 4 cases. There were two operative deaths (2.4%); both occurred after replacement, left ventricular rupture in one and DIC in one. Mean follow-up period was 4.5 years (range 1 to 17) in 67 cases. There were four late deaths; all occurred after replacement. However five patients sustained mild mitral insufficiency after mitral valve repair including one that became worse of regurgitation three years after isolated Kay's annuloplasty, there were no cases that had needed reoperation and no late death after reconstruction. Left ventricular function and pulmonary arterial pressure were almost normalized in more than 90% cases postoperatively. Our data indicated that mitral valve reconstruction (McGoon's plus Kay's method as standardized maneuver) was the procedure of choice for selected patients with mitral insufficiency owing to ruptured chordae tendineae to the posterior mitral leaflet, including more limited patients with ruptured chordae to the anterior mitral leaflet.     

Case of systolic anterior motion of mitral valve after mitral valve repair

A 56-year-old woman was underwent mitral valve repair for prolapse of the posterior mitral leaflet. Intraoperative transesophageal echocardiography (TEE) showed systolic anterior motion (SAM) of the mitral valve at the weaning from cardiopulmonary bypass (CPB). Sliding technique was easily performed at the second pump run. Intraoperative TEE demonstrated no SAM or residual mitral regurgitation after the second pump run.     

Replacement of ruptured chordae tendineae of the mitral valve with autologous pericardial chordae.

Severe mitral regurgitation owing to rupture of chordae tendineae has been repaired in 10 patients by construction of new chordae from autologous pericardium. The site of rupture was the posterior leaflet in eight patients, the anterior leaflet in one patient, and both leaflets in one patient. Cardiac catheterization demonstrated severe mitral regurgitation (average 49%) and a left atrial V wave of 45 mm. Hg. The reconstruction was carried out with pericardium rolled into a chorda with one end attached to the appropriate papillary muscle and the other attached to the flail edge of the mitral valve leaflet being repaired. One patient died on the seventh postoperative day from pneumonia. The remaining nine patients are alive and well (Functional Class I) from 6 months to 9 1/2 years (average 3 years) following the operation. None requires anticoagulants.     

Mitral valve insufficiency: suspension of the posterior leaflet to the mitral annuloplasty ring

Mitral valve insufficiency in rheumatic heart disease is often due to retracted posterior chordae and posterior leaflet thickening. Several surgical repair techniques have been described, but sometimes an acceptable coaptation of the mitral leaflets can not be achieved. Rather than accept a mitral regurgitation or resort to a mitral valve replacement, particularly in children, we have added a suspension of the posterior leaflet directly to the annuloplasty ring. This additional surgical repair technique was performed in 10 patients with a perfect coaptation of the mitral leaflets with immediate results and excellent mid-term results, without evidence of either mitral regurgitation, mitral valve stenosis, or leaflet abrasion due to the suspension sutures.     

Mital valve regurgitation with anterior mitral leaflet chordal rupture or elongation —Repair using the flip over technique—

Repair of prolapsed anterior mitral leaflet has remained technically difficult. The purpose of this study was to assess the clinical results after using the flip-over technique for patients with anterior mitral leaflet prolapse due to dhordal rupture or elongation. Between January 1993 and September 1997, fifteen adult patients with pure mitral valve regurgitation (MR) due to prolapse of the anterior mitral leaflet underwent repair using the flip-over technique. The indication for this procedure were; 1) all mitral structures except the prolapsed area must appear to be intact, and 2) the corresponding chordae attached to the posterior leaflet should be sufficiently strong to be transferred to the anterior leaflet. The prognoses following this technique were retrospectively studied to assess the early and mid-term clinical outcome of this procedure. Follow up was complete in all patients and ranged from 2 to 56 months (with a mean of 25 ± 17.9 months). There was no hospital death, None required reoperation. One patient died because of acute recurrent MR during follow-up. No other complication was experienced. Doppler echocardiographic studies at the final follow-up showed less than mild regurgitation in 11 (78.6%) of the 14 surviving patients. We believe that this procedure was effective for that the obtained repair of a prolapsed anterior mitral valve and early and mid-term clinical outcome from this procedure has been satisfactory.     

Hemodynamic performance of an unstented xenograft mitral valve substitute

OBJECTIVE: Stentless mitral xenografts offer potential clinical benefits because they mimic the normal bileaflet mitral valve. How best to implant them and their hemodynamic performance and durability, however, remain unknown. METHODS: A stentless porcine mitral xenograft valve (Medtronic physiologic mitral valve) was implanted in 7 sheep with papillary muscle sewing tubes attached with transmural left ventricular sutures. Radiopaque markers were inserted on the leaflets, annular cuff, papillary tips, and left ventricle. After 10 +/- 5 days, the animals were studied with biplane videofluoroscopy to determine 3-dimensional marker coordinates at baseline and during dobutamine infusion. Transesophageal echocardiography assessed mitral regurgitation and valvular gradients. Mitral annular area was calculated from the annular markers. Physiologic mitral valve leaflet and annular dynamics were compared with 8 native sheep valves. RESULTS: Average mitral regurgitation grade at baseline was 1.2 +/- 1.0 (range, 0-4), and the mean transvalvular pressure gradients were 3.6 +/- 1.3 and 6.2 +/- 2.2 mm Hg during baseline and dobutamine infusion, respectively. Xenograft mitral annular area contraction throughout the cardiac cycle was reduced (6% +/- 6% vs 13% +/- 4% for physiologic mitral valve and control valve, respectively; P =.03). Physiologic mitral valve leaflet geometry during closure differed from the native valve, with the anterior leaflet being convex to the atrium and with little motion of the posterior leaflet. Three animals survived more than 3 months; good healing of the annular cuff and papillary muscle tubes was demonstrated. CONCLUSION: This stentless xenograft mitral valve substitute had low gradients at baseline and during stress conditions early postoperatively, with mild mitral regurgitation. Preliminary analysis of healing characteristics appeared favorable at 3 months. Additional studies are needed to determine long-term xenograft mitral valve performance and resistance to calcification.     

Imbalanced chordal force distribution causes acute ischemic mitral regurgitation: mechanistic insights from chordae tendineae force measurements in pigs

BACKGROUND: Ischemic mitral regurgitation is caused by an imbalance of the entire mitral-ventricular complex. This interaction is mediated through the chordae tendineae force distribution, which may perturb several elements of the mitral valve apparatus. Our objective was to investigate the association between the mitral valvular 3-dimensional geometric perturbations and chordae tendineae force redistribution in a porcine model of acute ischemic mitral regurgitation. METHODS: In 9 pigs, acute ischemic mitral regurgitation was induced by repeated microembolization of the left circumflex coronary artery. Mitral leaflet coaptation geometry was determined by 2-dimensional echocardiography and reconstructed 3-dimensionally. Leading edge chordal forces were measured by dedicated miniature force transducers at control and during ischemic mitral regurgitation. RESULTS: During acute ischemic mitral regurgitation, there was a decreased tension of the primary chorda from the ischemic posterior left ventricular wall to the anterior leaflet (0.295 +/- 0.063 N vs 0.336 +/- 0.071 N [control]; P < .05). The tension of the chorda from the nonischemic anterior left ventricular wall to the anterior leaflet increased (0.375 +/- 0.066 N vs 0.333 +/- 0.071 N [control]; P < .05). In accordance, relative leaflet prolapse was observed at the ischemic commissural side, whereas there was an increase in the leaflet surface area at the nonischemic commissural side, indicating localized leaflet tethering. CONCLUSIONS: Acute ischemic mitral regurgitation due to posterior left ventricular wall ischemia was associated with focal chordal and leaflet tethering at the nonischemic commissural portion of the mitral valve and a paradoxical decrease of the chordal forces and relative prolapse at the ischemic site of the anterior mitral valve leaflet.