Repair of bileaflet prolapse in Barlow syndrome

Mitral valve (MV) leaflet billowing, prolapse, and excessive tissue are hallmarks of Barlow syndrome. Successful MV repair can be a challenge in these oftentimes young and otherwise healthy patients. We herein present details on our stepwise approach to MV repair for Barlow syndrome including: (1) surgical approach; (2) MV exposure; (3) assessment of MV pathology; (4) repair of leaflet prolapse; (5) choice and sizing of annuloplasty ring; and (6) fine-tuning and troubleshooting. Our repair strategy involves extensive use of Gore-Tex neochordae using the so-called "loop technique." We have used this operative strategy via a right mini-thoracotomy in 436 patients with bileaflet prolapse and 144 patients with Barlow syndrome. Our successful MV repair rate is 95% in patients with Barlow syndrome and the ten-year freedom from reoperation rate is 96% for such patients. We can conclude that a stepwise approach to this MV pathology with extensive use of the loop technique can result in very acceptable outcomes, even in patients undergoing minimal invasive surgery.     

Advanced experience allows robotic mitral valve repair in the presence of extensive mitral annular calcification

ObjectiveMitral annular calcification is underdiagnosed in patients with mitral regurgitation. After excision, it may require reconstruction of the atrioventricular groove and decreases the probability of valve repair. We reviewed the safety and efficacy of totally endoscopic robotic mitral valve repair in the presence of mitral annular calcification, with an emphasis on pathology and repair techniques.MethodsBetween May 2011 and August 2017, the same 2-surgeon team attempted totally endoscopic robotic mitral valve repair in 64 mitral annular calcification cases, accounting for 12.8% of our experience. Mitral annular calcification associated with a calcified posterior leaflet was not considered for totally endoscopic robotic mitral valve repair. When possible, the mitral annular calcification was excised en bloc using electrocautery, the posterior leaflet separated from the mitral annular calcification and spared, the atrioventricular groove was reconstructed, the posterior leaflet was reattached to the neoannulus, and the repair was completed with annuloplasty.ResultsThe median age of patients was 65 years, with 21 (32.8%) aged less than 60 years, and 34 (53.1%) were women. The etiology was Barlow's disease in 54 patients (84%). Repair was converted to replacement in 2 patients (3.1%). Cryoablation was performed in 8 patients (12.5%), hybrid percutaneous coronary intervention was performed in 5 patients (7.8%), and tricuspid annuloplasty was performed in 2 patients (3.1%). Median aortic occlusion was 122 minutes, excluding cases with concomitant tricuspid repair. Thirty-three patients (52%) were extubated in the operating room. The median length of stay was 4 days. Residual mitral regurgitation on discharge transthoracic echocardiogram was none to mild in all patients. None of the patients had a perioperative stroke or needed a pacemaker. Thirty-day mortality was 2 (3.1%).ConclusionsMitral annular calcification is present in a significant percentage of patients with mitral regurgitation, especially in Barlow's disease, including younger patients. By using a variety of repair techniques, totally endoscopic robotic mitral valve repair can be performed safely and effectively in most mitral annular calcification cases with a noncalcified posterior leaflet.     

Comparison of outcomes of minimally invasive mitral valve surgery for posterior, anterior and bileaflet prolapse

Objective: We sought to compare the outcomes of minimally invasive mitral valve (MV) surgery for anterior (anterior mitral leaflet, AML), posterior (posterior mitral leaflet, PML) or bileaflet (BL) MV prolapse. Methods: Between August 1999 and December 2007, 1230 patients who presented with isolated AML (n = 156, 12.7%), isolated PML (n = 672, 54.6%) or BL (n = 402, 32.7%) MV prolapse underwent minimally invasive MV surgery. The preoperative mitral regurgitation (MR) grade was 3.3 ± 0.8, left ventricular ejection fraction (LVEF) was 62 ± 12% and mean age was 58.9 ± 13.0 years; 836 patients (68.0%) were male. Mean follow-up time was 2.7 ± 2.1 years, and the follow-up was 100% complete. Results: Overall, the MV repair rate was 94.0% (1156 patients). Seventy-four patients (6.0%) received MV replacement. MV repair for PML prolapse was accomplished in 651 patients (96.9%), for AML in 142 patients (91%) and for BL in 363 patients (90.3%). Repair techniques consisted predominantly of leaflet resection and/or implantation of neochordae, combined with ring annuloplasty. Concomitant procedures were tricuspid valve surgery (n = 56), atrial fibrillation ablation (n = 286) and closure of an atrial septal defect or patent foramen ovale (PFO) (n = 89). The overall duration of cardiopulmonary bypass was 127 ± 40 min and aortic cross-clamp time was 78 ± 33 min. The mean postoperative hospital stay was 11.6 ± 9.7 days for the overall group. Early echocardiographic follow-up revealed excellent valve function in the vast majority of patients, regardless of the repair technique, with a mean MR grade of 0.3 ± 0.5. For the overall group, 5-year survival rate was 87.3% (95% CI: 83.9–90.1) and 5-year freedom from cardiac reoperation rate was 95.6% (95% CI: 94.1–96.7). The log-rank test revealed no significant difference between the three groups regarding long-term survival or freedom from reoperation. Conclusions: Minimally invasive MV repair can be achieved with excellent results. Long-term outcomes and reoperation rates for AML prolapse are not significantly different from PML or BL prolapse.     

Ischemic mitral valve repair: Correlations between the mechanisms of mitral regurgitation and left ventricular function prior to and following surgery

Objective.?To define the mechanisms of ischemic mitral regurgitation (MR) and its correlation with left ventricular (LV) function prior to and 1 year following mitral valve (MV) repair. Design.?Fifty-three patients (pts) underwent echocardiographic evaluation of the MR mechanism according to Carpentier's classification; quantification of MR and LV function. Results.?Forty-one, 5% of pts had Type I (annulus dilation), 20, 5% had Type II (commissural prolapse) and 38% had Type IIIb MR (predominant posterior leaflet restriction). Preoperative LV function was slightly better preserved in pts with Type II and IIIb MR. Despite similar MV repair efficiency intraoperatively, after 1 year Type I MR progressed vs the remaining types. LV function, including dimensions, ejection fraction and pulmonary artery pressure had a tendency to worsen in pts with Type I and markedly improved in Type II and IIIb MR. Conclusions.?Ischemic MR of Type I is associated with more marked LV dysfunction preoperatively, its further deterioration and MR progression after MV repair. Type II and IIIb MR correlates with better preserved LV function preoperatively and its incremental improvement late after surgery.     

A novel cross-species model of Barlow's disease to biomechanically analyze repair techniques in an ex vivo left heart simulator

ObjectiveBarlow's disease remains challenging to repair, given the complex valvular morphology and lack of quantitative data to compare techniques. Although there have been recent strides in ex vivo evaluation of cardiac mechanics, to our knowledge, there is no disease model that accurately simulates the morphology and pathophysiology of Barlow's disease. The purpose of this study was to design such a model.MethodsTo simulate Barlow's disease, a cross-species ex vivo model was developed. Bovine mitral valves (n = 4) were sewn into a porcine annulus mount to create excess leaflet tissue and elongated chordae. A heart simulator generated physiologic conditions while hemodynamic data, high-speed videography, and chordal force measurements were collected. The regurgitant valves were repaired using nonresectional repair techniques such as neochord placement.ResultsThe model successfully imitated the complexities of Barlow's disease, including redundant, billowing bileaflet tissues with notable regurgitation. After repair, hemodynamic data confirmed reduction of mitral leakage volume (25.9 ± 2.9 vs 2.1 ± 1.8 mL, P < .001) and strain gauge analysis revealed lower primary chordae forces (0.51 ± 0.17 vs 0.10 ± 0.05 N, P < .001). In addition, the maximum rate of change of force was significantly lower postrepair for both primary (30.80 ± 11.38 vs 8.59 ± 4.83 N/s, P < .001) and secondary chordae (33.52 ± 10.59 vs 19.07 ± 7.00 N/s, P = .006).ConclusionsThis study provides insight into the biomechanics of Barlow's disease, including sharply fluctuating force profiles experienced by elongated chordae prerepair, as well as restoration of primary chordae forces postrepair. Our disease model facilitates further in-depth analyses to optimize the repair of Barlow's disease.     

Reoperation in mitral valve repair for regurgitant mitral valve disease

Objectives: Reviewing reoperative mitral valve repair, we evaluated a predictor for future reoperation by comparing degenerative and rheumatic mitral regurgitation. Methods: From June 1988 to September 2002, 159 patients with mitral valve regurgitation underwent a variety of surgical reconstruction. Our 9 subjects −2 men and 7 women with a mean age of 55.3 years—including 1 undergoing initial repair at an other hospital, underwent reoperation for mitral valve lesions. Four patients had rheumatic (Group R) and 5 degenerative (Group D) mitral valve disease. We studied reoperative outcomes and initial procedures were retrospectively. Results: The mean interval from initial repair was 111 months. Mitral valve lesions at reoperation in Group D were annular dilation in 3, leaflet prolapse in 1, and suture disruption in 1, while that in Group R involved severe thickening of both leafle. Rerepair was possible in 3 patients of Group D, but all others, (including Group R patients) required valve replacement. All survived reoperation. Conclusions: Rerepair in rheumatic mitral regurgitation, rerepair was difficult. In degenerative mitral valve regurgitation, however, rerepair was possible because procedure-related origin was a major cause of reoperation. Reoperation can be prevented by proper technical improvement at initial repair.     

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.     

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. Read at the Fifty-fifth Annual Meeting of The Japanese Association for Thoracic Surgery, Symposium, Fukuoka, October 9–11, 2002.     

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.     

Surgical Application for a Prolapse of the Anterior Mitral Leaflet by Replacing Artificial Chordae with Polytetrafluoroethylene Grafts

Purpose There are an increasing number of reports concerning mitral valve repair by a reconstruction of the chordae tendinae using expanded polytetrafluoro-ethylene (PTFE) sutures. However, little information is available about extended application or results of this technique for an extended prolapse of the anterior mitral leaflets.Methods Between July 1991 and August 2003, 28 patients with moderate to severe mitral regurgitation as a result of a prolapse of anterior leaflets (age range, 15–73 years) underwent mitral valve repair by reconstruction of the artificial chordae with 4-CV expanded polytetrafluoroethylene sutures without a leaflet resection. Either Kay’s suture technique or ring annuloplasty was also performed to correct annular dilatation in all patients.Results No operative death or late mortality was observed. The prolapsed segment, which was successfully repaired, was within 33% of the anterior mitral leaflet (AML) in 6 patients, from 33% to 50% in 5, from 50% to 99% in 11, and 100% in 6 patients. Before discharge, immediate postoperative echocardiography showed less than moderate mitral regurgitation in 28 of 28 patients. The follow-up, consisting of a clinical examination and serial echocardiograms, was complete in all cases and the mean follow-up period was 80.6 months (range, 12–146). There were two failures that required a reoperation because of a worsening mitral regurgitation and hemolytic anemia (elongation of anchored side of papillary muscle). The other two patients required mitral valve replacement due to a progressive regression of the left ventricular function, although the regurgitation worsened from a mild level to a moderate one. When the reoperated patients were excluded from the following data, the degree of mitral regurgitation, estimated by echocardiography performed at recent follow-up period, was none in 10 patients, trivial in 13 patients, and mild in 1 patient. In addition, the systolic and diastolic dimensions of the left ventricle decreased significantly (P < 0.01).Conclusions The replacement of artificial chordae was not complicated and it seemed to help to preserve a good relationship among leaflet tissues, chordae, and papillary muscles. We therefore suggest that the extensive use of PTFE artificial chordae appears to be a promising procedure for the repair of all kinds of mitral lesions causing mitral regurgitation.     

Choosing the “Best” surgical techniques for mitral valve repair: Lessons from the literature

Mitral valve (MV) repair is the procedure of choice to correct mitral regurgitation caused by degenerative MV disease, due to its well‐documented superiority over MV replacement. Repair of the MV is feasible in more than 95% of such patients and restores valve function and preserve ventricular function. Surgeons choose from a wide variety of mitral repair techniques, with the ultimate procedure based upon the pathology and the particular surgeon's personal preference. As a result, there is considerable controversy concerning choice of repair techniques and prostheses (ie, annuloplasty device). This targeted review of available data concerning repair of the degenerative valve will inform surgeon decision‐making in MV repair.     

Evolution from mitral annular dysfunction to severe mitral regurgitation in Barlow’s disease

OBJECTIVESBarlow’s disease (BD) is characterized by thick, redundant mitral valve (MV) leaflets, which can lead to prolapse and significant mitral regurgitation (MR). MV annular abnormalities are also commonly observed and increasingly recognized as possible primary pathology, with leaflet thickening being secondary to increased stress on the MV apparatus. To provide more insights into this hypothesis, the evolution of MV abnormalities over time in patients with BD was assessed.Open in a separate windowMETHODSA total of 64 patients (54 ± 12 years, 72% male) with BD who underwent MV surgery and had multiple transthoracic echocardiograms (TTE) before surgery were included. In total, 186 TTE were analysed (median time interval 4.2, interquartile range 2.2–6.5 years) including specific MV characteristics.RESULTSAt baseline, MV leaflet length, thickness, billowing height and annular diameter were larger in patients with BD compared to 59 healthy subjects. Systolic outward motion (curling) of the annulus was observed in 77% and severe mitral annular disjunction (≥5 mm) in 38% of patients with BD. Forty (63%) patients had MR grade I–II and 24 (37%) MR grade III–IV; at baseline, the 2 groups only differed in left atrial volume and in thickness and billowing height of the posterior leaflet, showing comparable MV annular abnormalities and dilatation despite different grades of MR. Over time, MV annulus diameter, leaflet length and billowing height increased significantly along with MR grade.CONCLUSIONSIn patients with BD, MV annulus abnormalities are present at an early stage and precede the development of significant MR, suggesting their substantial role in the pathophysiology of this disease and as an important target for surgical treatment.     

二尖瓣成形术的临床研究(附131例报告)

目的 总结二尖瓣成形手术方法 和临床效果.方法 对131例各种病因引起的二尖瓣关闭不全实施成形手术,术中发现二尖瓣的病理改变有瓣环扩大、瓣叶脱垂、瓣叶裂、瓣叶增厚、钙化、赘生物形成和腱索断裂、三瓣化等.成形的方法有:瓣环环缩、交界缝缩、补片扩大前叶、双孔成形、后叶矩形切除、钙化灶及赘生物切除、人工瓣环植入等.术中采用注水试验和经食管超声检查成形效果.结果 手术死亡2例,二次开胸止血3例,急性肾功能衰竭2例.术后1周、3个月及9个月心脏彩超检查:左房内径、左室舒张末径缩小,左室射血分数提高.术后9个月心脏彩超检查:无或轻度返流98例,中度返流29例,重度返流2例(1例于10个月后行二尖瓣置换术).结论 术中根据瓣膜不同的病理改变特点,灵活采用多种成形方法 ,可以取得较好的成形效果,术中经食管超声或注水试验效果不佳者,应考虑瓣膜置换.     

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.     

Mitral annular reconstruction with anterior leaflet flip-over in concomitant surgery for mitral regurgitation associated with extensive posterior annular calcification and hypertrophic obstructive cardiomyopathy

We describe a case of severely calcified posterior mitral annulus associated with grade IV mitral re-gurgitation in addition to significant hypertrophic obstructive cardiomyopathy. A 70-year-old woman underwent successfully annular reconstruction with anterior mitral leaflet flip-over and mitral valve replacement with a bileaflet mechanical prosthesis combined with left ventricular septal myectomy. This technique can serve not only to cover the debrided posterior annulus, but also to eliminate left ventricular outflow tract obstruction and to keep left ventricular function by virtue of not severing ventricular-annular continuity.     

Artificial chordae for pediatric mitral and tricuspid valve repair.

OBJECTIVE: To evaluate pediatric atrioventricular valve repair with artificial chordae. METHODS: Between February 2001 and January 2006, artificial chords were used in 21 children with severe mitral or tricuspid valve regurgitation. Patients with AVSD were excluded. Median age was 84 (1-194) months. Five patients had isolated tricuspid valve anomalies, 16 had mitral valve anomalies (associated tricuspid annular dilatation in 4). Tricuspid neochordae were placed to anterior (three patients) and septal (two patients) leaflets. Mitral neochordae were placed to anterior (15 patients) and posterior (1 patient) leaflets. Additional ring annuloplasties were performed in 12 (mitral 11, tricuspid 1), as well as 2 de Vega tricuspid annuloplasties. Patch insertion was used in acute endocarditis (tricuspid one). All echocardiographic studies were reviewed and analyzed by a single cardiologist. RESULTS: No mortality occurred. Follow-up was complete (mean 28+/-18 months). Two patients were reoperated, one for mitral ring dehiscence and one for recurring mitral valve insufficiency. Both valves were replaced by mechanical valve prosthesis. At last follow-up tricuspid insufficiency was mild (three) or moderate (two). Moderate insufficiency occurred due to remaining restriction of the septal leaflet after repair in endocarditis (one) and remaining prolapse of the anterior leaflet (one). Mitral insufficiency was absent (five), mild (seven), or moderate (two). Moderate insufficiency was caused by recurrent anterior leaflet shortening after valve repair in rheumatic valve disease (two). Valve restriction caused by artificial chordae was not found. CONCLUSIONS: Mitral and tricuspid valve repair with artificial chordae in children demonstrated acceptable results. Despite patient growth, valvular restriction by the artificial chordae was not observed ad mid-term follow-up.     

Principles of reconstructive surgery in degenerative mitral valve disease

Degenerative mitral valve disease is the most common cause of mitral regurgitation (MR) in developed countries. The most common etiologies of valvular regurgitation are Barlow's disease and fibroelastic deficiency. The mechanism of MR is type II dysfunction (leaflet prolapse) due to chordae elongation or rupture in most patients. Associated annular dilation is a common lesion in almost all patients with chronic MR. By means of segmental valve analysis, isolated posterior leaflet prolapse (P2 segment) is often observed in patients with fibroelastic deficiency, whereas the prolapse of multiple segments or bileaflet prolapse is typically seen in patients with Barlow's disease. In patients with degenerative mitral valve disease and severe MR, reconstructive surgery should be performed before the occurrence of clinical symptoms, atrial fibrillation, pulmonary hypertension, and left ventricular dysfunction or enlargement. The goals of reconstructive surgery are preservation or restoration of normal leaflet motion, creation of a large surface of coaptation, and stabilization of the entire annulus with a remodeling annuloplasty. Today, reconstructive techniques are standardized, reliable, and reproducible, and therefore should be applied systematically to all patients with degenerative valvular disease.     

Gore-tex chordoplasty in degenerative mitral valve repair

Mitral valve repair with Gore-Tex (W.L. Gore & Assoc, Inc, Flagstaff, AZ) neochordae is of increasing interest. In 2000, the loop technique using premeasured Gore-Tex neochordae was introduced by our group. Herein, we report our experience with this technique in minimally invasive mitral valve repair (MVR) for degenerative disease. Between 1999 and 2006, 468 patients (328 men and 140 women) underwent elective MVR using neochordae at our institution. The mean age of the patients was 58 +/- 12.3 years. All patients had significant mitral valve regurgitation, and the mean severity was 3.5 +/- 0.6. Prolapse of the posterior leaflet was diagnosed in 393 patients (84%), and prolapse of the anterior leaflet was diagnosed in 250 patients (53.4%). Mean left ventricular function was 64.8 +/- 12.3%. All patients were operated on with the minimally invasive approach via a right lateral mini-thoracotomy, femoral cannulation for cardiopulmonary bypass, and the transthoracic direct clamp technique. Mean duration of cardiopulmonary bypass was 136 +/- 40 minutes, and mean aortic clamp time was 87 +/- 31 minutes. Gore-Tex neochordae were used in 149 patients (32%) on both leaflets, in 224 patients (47.7%) on the posterior leaflet only, and in 95 patients (20.3%) on the anterior leaflet only. A mean number of 2.7 +/- 1 loops at a mean length of 21 +/- 3.3 mm were used on the A2 segment. On the P2 segment, a mean number of 3.2 +/- 1 loops at a mean length of 14.3 +/- 3.1 mm were applied. The intraoperative course was uneventful in all patients. Early reoperation for bleeding had to be performed in 18 patients (3.9%). Mean duration of hospital stay was 11.9 +/- 13 days. The 30-day mortality rate was 1.5% (7 patients), and 1-year mortality rate was 2.6% (12 patients). MVR with neochordae and the loop technique is an easy and effective treatment for degenerative mitral valve disease. The procedure is reliable and reproducible, leading to low morbidity and mortality. Thus, use of Gore-Tex neochordae has become the standard technique for MVR at our institution.     

Beating-heart implantation of adjustable length mitral valve chordae: acute and chronic experience in an animal model

Objective: This study aimed to determine the acute and chronic performance of a new system designed to conduct beating-heart implantation and off-pump adjustment of neochordal length. Methods: In 14 adult sheep (group A) selected to undergo beating-heart cardiopulmonary bypass, the left atrium was opened through a left thoracotomy. Two or more primary chordae in the A2 region were severed to produce a model of a flail leaflet. A chordal adjustment mechanism (V-Chordal, Valtech Cardio Ltd., Or-Yehuda, Israel) was affixed to the head of the papillary muscle. The system includes two adjustable neochordae. The distal end of the neochordae was sutured to the flail segment without estimating the appropriate length. The neochordal length was adjusted off-pump under real-time echo-guidance. The adjustment tool was removed and the atriotomy was closed with a purse-string suture. Control animals (group B, n = 4) were implanted with the conventional neochordae. Animals in both groups were sacrificed 3 months after the procedure. Results: In both groups, prior to repair, mitral regurgitation (MR) was severe in all animals. In group A, following adjustment of neochordae, MR was absent in all animals, with the exception of two animals that had residual 2+ MR irresponsive to neochordae adjustments. In group B, MR was 2+ in two of the four animals following repair. At 3 months, mitral competence was stable in all animals. At necropsy, normal healing of the papillary head and leaflet was observed in both the groups. Conclusions: The V-Chordal system simplifies the process of neochordal implantation and precise off-pump adjustment of the neochordal length to correct MR occurring due to a flail leaflet. This technology may improve the technical feasibility for adoption of chordal repair during open or minimally invasive surgical procedures.     

Mitral valve repair for degenerative disease with leaflet prolapse: to improve long-term outcomes

Purpose  Residual mitral regurgitation (MR) is a risk factor of reoperation. Here we report the midterm results of mitral valve repair for degenerative disease with mitral valve prolapse and identify important factors for durable repair. Methods  From April 1999 to September 2007, 116 patients with leaflet prolapse (59 men; mean age 63 years) underwent mitral valve repair; they consisted of 19 anterior, 67 posterior, 23 bileaflet, and 7 isolated commissures. The mean clinical and echocardiographic follow-ups were at 4.1 ± 2.3 and 3.3 ± 2.4 years, respectively. Results  Altogether, 12 patients showed recurrent moderate or severe MR during the follow-up period; and 10 of the 12 patients (83.8%) had recurrent moderate or severe MR within 1.5 years. Causes of early MR recurrence were dehiscence of sutured segments and ineffectiveness of the artificial chords. The rates of freedom from reoperation at 3 and 7 years were 95.3% ± 2.0% and 91.0% ± 4.7%, respectively. The rates of freedom from recurrent moderate or severe MR at 3 and 7 years were 90.5% ± 2.9% and 83.8% ± 5.9%, respectively. Conclusions  The prevention of dehiscence of the sutured segment and reestablishment of coaptation using artifi- cial chords are imperative to maintain the durability of mitral valve repair for patients with degenerative disease. This study was presented at the 60th annual scientific meeting of the Japanese Association for Thoracic Surgery.