Interact CardioVasc Thorac Surg 2007;6:580-581. doi:10.1510/icvts.2007.158808
© 2007 European Association of Cardio-Thoracic Surgery
Intraoperative saline injection leak test – a simple method to assess mitral valve repair when a simultaneous aortotomy does not allow pressurization of the left ventricle
Masato Nakajimaa,*,
Koji Tsuchiyaa,
Yuki Okamotoa and
Fuminaga Suetsugub
a Department of Cardiovascular Surgery, Yamanashi Central Hospital, 1-1-1 Fujimi, Kofu, Yamanashi, 400-0027 Japan
b Department of Cardiovascular Surgery, Suetsugu Clinic, Fukuoka, Japan
Received 2 May 2007;
received in revised form 18 May 2007;
accepted 19 May 2007
*Corresponding author: T el.: +81-55-253-7111; fax: +81-55-253-8011.
E-mail address: m-nakajima2a{at}ych.pref.yamanashi.jp (M. Nakajima).
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Abstract
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We describe a simple, safe and reliable intraoperative saline injection leak test for accomplishing and testing the efficacy of mitral valve repair when a simultaneous aortotomy is present.
Key Words: Mitral valve repair; Leak test; Aortotomy
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1. Introduction
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Intraoperative assessment of a competency of the repaired mitral valve before closure of the atrium is an important step in accomplishing successful mitral valve repair. Saline test injection into the left ventricle under pressure is the most popular and reliable method to evaluate the repaired mitral valve. However, in patients requiring repair of an aortic valve simultaneously, the saline test becomes unreliable because the ascending aorta is open. We describe a simple and reliable intraoperative saline injection leak test for mitral valve repair when a simultaneous aortotomy is present.
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2. Technique
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In our practice, all combined valve procedures are performed through a median sternotomy with transesophageal echocardiography routinely used for pre- and postrepair evaluation of the mitral valve. Standard cardiopulmonary bypass is instituted with bicaval venous cannulation and ascending aortic return, and left heart venting via the right upper pulmonary vein. In cases with competent aortic valve, the left atrium is incised first on the interatrial groove, extending posteriorly beneath both caval veins under ventricular fibrillation, mitral valve analysis is performed carefully. In cases with moderate to severe aortic insufficiency, the aorta is cross-clamped promptly and cardioplegia is infused directly within the coronary ostia following an oblique aortotomy. If the aortic valve is severely calcified, careful resection of the aortic valve is performed prior to mitral valve repair in order to obtain good visualization of the mitral valve. The mitral valve is then repaired using various techniques according to the lesions. After repair of the mitral valve, the competency is evaluated using saline injection leak while simultaneously occluding the left ventricular outflow tract with a balloon catheter (20 Fr Foley catheter) inserted through the aortotomy (Fig. 1a,b). After confirmation of a satisfactory mitral repair, the aortic valve is replaced.
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Fig. 1. (a) Catheter was inserted into the left ventricular cavity through aortotomy incision and the left ventricular outflow tract was occluded by inflation of the attached balloon. (b) Left ventricular cavity is filled and pressurized with saline injection for confirmation of the competency of the repaired mitral valve.
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3. Results
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From December 1991 to December 2006, twenty-four patients with mitral regurgitation in association with aortic valve disease underwent mitral valve repair and concomitant aortic valve replacement. The group comprised twelve men and twelve women whose mean age was 60.3 years (26–88 years). Twenty-three patients required aortic valve replacement with a mechanical prosthesis and one open aortic valvuloplasty. The etiology of mitral lesions and the repair techniques utilized are summarized in Table 1. Operation time, cardiopulmonary bypass time, and aortic cross-clamp time were 241±61, 114±17.7, and 78± 14.4 min, respectively. All patients were weaned easily from cardiopulmonary bypass without the need for mitral repair revision. No discrepancy was found between the findings of the intraoperative leak test performed with the technique described herein and post-bypass echocardiogram. Pre-discharge echocardiogram disclosed no significant mitral regurgitation in any of the patients included in the series. There were no major morbidities and no mortalities.
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4. Discussion
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There has been some controversy surrounding patients with combined aortic and mitral valve disease. The durability and outcome of combined aortic valve replacement and mitral valve repair vs. double valve replacement remain to be determined. However, recent reports described the superiority of mitral valve repair especially in cases with degenerative aortic and mitral valve disease [1].
When attempting mitral valve repair, intraoperative assessment of the competency of the mitral valve before closure of the atrium is important. Saline injection pressurization of the left ventricle and infusion of cardioplegic solution within the aortic root (the latter in the presence of at least mild aortic regurgitation and in the absence of an aortotomy) are considered to be the most common and reliable techniques used to inspect the repaired valve [2, 3]. However, this becomes very difficult in cases requiring simultaneous repair of an aortic valve, since the aorta is opened. To our knowledge, no reliable alternative has been previously described.
Occlusion of the ascending aorta below the incision line by simple clamp is considered to be difficult and hazardous, and potentially injures the surrounding tissues. Repairing the mitral valve after completion of the aortic valve procedure and closure of the aortotomy is rather difficult due to poor visibility and limitation of the working space, especially around the antero-lateral commissure when the aortic prosthesis has already been seated. The additional retraction can also potentially damage the aorta just around the site where the prosthesis is inserted. The saline injection leak test described here is a simple, safe and reliable method for accomplishing and testing the efficacy of mitral valve repair when, by necessity, the aortic root is open.
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References
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- Gillinov AM, Blackstone EH, Cosgrove DM, White J, Kerr P, Marullo A, McCarthy PM, Lytle BW. Mitral valve repair with aortic valve replacement is superior to double valve replacement. J Thorac Cardiovasc Surg 2003; 125:1372–1387.[Abstract/Free Full Text]
- Kouchoukos NT, Blackstone EH, Doty DB, Hanley FL, Karp RB. Cardiac Surgery 3rd ed. In: Kirklin JW, Barratt-Boyes BG. Churchill Livingstone2003; 483–554. In:.
- Muehrcke DD, Cosgrove DM. Cohn LH, Edmunds Jr LH. Mitral valvuloplasty. eds Cardiac Surgery in the Adult 2nd ed 2003;New York, NY: McGraw-Hill 991–1025. In:.
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Abstract
1. Introduction