Interact CardioVasc Thorac Surg 2009;9:287-290. doi:10.1510/icvts.2009.204776
© 2009 European Association of Cardio-Thoracic Surgery
Institutional report - Valves |
Echocardiographic assessment of mitral valve morphology and performance after triangular resection of the prolapsing posterior leaflet for degenerative myxomatous disease
Bruno Chiappinia,
Renato Gregorinia,
Franco De Remigisa,
Licia Petrellaa,
Carmine Villania,
Fabrizio Di Pietrantonioa,
Srdan Pavicevicb and
Alessandro Mazzolaa,*
a Department of Cardiac Surgery, Giuseppe Mazzini Hospital, Piazzale San Padre Pio, 64100 Teramo, Italy
b Department of Cardiac Surgery, Clinic Center of Podgorica, Montenegro
Received 6 February 2009;
received in revised form 15 April 2009;
accepted 15 April 2009
*Corresponding author. Tel.: +39 0861 429686; fax: +39 0861 429687.
E-mail address: sandromaz{at}tin.it (A. Mazzola).
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Abstract
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The gold standard for the surgical treatment of prolapse of the posterior leaflet of the mitral valve (MV) for degenerative myxomatous disease has been represented by the quadrangular resection of the leaflet, according to the Carpentier technique. Since 2006 we performed a triangular resection of the prolapsing leaflet in 20 patients with myxomatous mitral regurgitation (MR). Seventeen patients (85%) underwent the triangular resection of P2; one patient (5%) had a triple scallops triangular resection (P1, P2, P3) and two (10%) a double scallops (P2, P3) resection. In this study, we report the immediate and mid-term clinical and echocardiographic results of a cohort of 20 patients, who underwent this technique. Thirty-day mortality was 0. Acute renal failure occurred in three patients (15%) and they resolved with conservative management. One patient (5%) required re-exploration for bleeding. At the mean follow-up of 13.1±4.2 months survival was 95%; one patient died of lymphoma during the follow-up time. All the cases were in New York Heart Association (NYHA) class I. Nineteen survivors underwent transthoracic echocardiography (TTE) (5), or transesophageal echocardiography (TEE) (13), performed by two skilled cardiologists. All patients showed no or trivial MV regurgitation. We believe that triangular resection of posterior MV leaflet (PMVL) provides excellent mid-term results providing the surgeon with a reliable and reproducible surgical option for myxomatous degenerative MV regurgitation.
Key Words: Mitral valve repair
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1. Introduction
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Mitral valve (MV) prolapse has been described in up to 17% of the population and degenerative disease is currently the most common cause of mitral regurgitation (MR) in the Western countries, following the decrease of postrheumatic valve disease [1, 2]. Despite this, MV repair should be performed in approximately 80–90% of the patients suffering from degenerative MV disease, with evident advantages, it is now only performed in 40% of patients, in the international literature referring to MV disease due to all causes, because of the complexity of the surgical repair techniques, especially in the case of multiple prolapses, severe myxoid degeneration of all the scallops, as in Barlow disease and in the presence of a degenerative fibroelastic deficiency [3]. MR for degenerative valve disease is most commonly due to the segmental leaflet prolapse and, statistically, the P2 scallop is the most commonly involved. During the last two decades, the gold standard for the surgical treatment of this disease has been represented by the quadrangular resection of the leaflet, according to the Carpentier technique [4]. Encouraged by the early results of the group of the Mayo Clinic [5], in 2006 we begun to prefer a triangular resection of the prolapse in order to excise a scalloped triangular-shaped segment of the prolapsing leaflet, with the base at the leading edge and the apex towards the annulus of the MV. In this study we report the immediate and mid-term clinical and echocardiographic results of a cohort of 19 patients, who underwent this technique.
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2. Material and methods
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During the period from December 2006 to May 2008, 153 MV operations were performed at our institution: 79 (51.6%) replacements and 74 (48.4%) repairs and of these 20 patients had a triangular resection of the prolapsing MV posterior leaflet. Clinical characteristics of the population are shown in Table 1. Seventeen patients (85%) underwent the triangular resection of P2; we also performed a triple scallops triangular resection (P1, P2, P3) in one patient (5%) and a double scallops (P2, P3) resection in two patients (10%).
2.1. Operative techniques
After the induction of anesthesia, an intraoperative trans-esophageal echocardiography (TEE) was performed. A median sternotomy was performed and patients were placed on cardiopulmonary bypass (CPB) using standard techniques. If coronary artery bypass grafting (CABG) or a radiofrequency ablation for atrial fibrillation (AF) was performed, this was done before the MV repair, while tricuspid and aortic valve (AV) surgery were done after the MV procedure. MV is approached by the left atrium through Waterston's groove. A left atrial retractor was used to expose the MV. The myxomatous degenerative etiology was defined on the basis of the preoperative echocardiography and the gross appearance of the valve that was accurately inspected to confirm the preoperative echocardiographic findings, using the two conceptual approaches, functional and segmental, as described by Carpentier [6]. With the aid of a nerve hook, the free edge of P1 was compared with A1, then P2 with A2 and P3 with A3 in order to create a three-dimensional understanding of the leaflets relationship. The size and extent of the resection were carefully matched to the extent of the bulging. Two 5/0 Prolene (Ethicon Inc, Sommerville, New Jersey, USA) stay sutures were attached to the free edge of each scallop, carefully sparing the major chordae to delineate the involved area. The flail segment of the leaflet was then excised as a triangular-shaped segment with the base of the triangle at the leading edge of the valve leaflet and the apex towards the annulus (Fig. 1). The edges of each remaining posterior leaflet scallop were then approximated and sewn using 4/0 Ethibond (Ethicon Inc, Sommerville, New Jersey, USA) single stitches. The sutures were placed in an inverted fashion with the knot buried on the ventricular side: this maneuver promotes overlap with the anterior leaflet, which is essential for mitral competence. The repair was then completed by implanting the Cosgrove's band (Edwards Lifesciences, Irvine, CA), sized to the anterior MV leaflet and the intertrigonal distance. Once the annuloplasty was completed, MV repair was tested by filling the left ventricle with saline solution in order to assess the presence of a residual leak. The patient was weaned from CPB in standard fashion. TEE was immediately performed to confirm the adequacy of the repair: the presence of more than trivial (grade I) MR was judged unacceptable.
2.2. Statistical analysis
Continuous variables are reported as mean±S.D. and categorical variables as proportions. Survival curve was computed with the Kaplan–Meier method. The SPSS 13.0 software was used for the statistical analysis (SPSS Inc, Chicago, Illinois).
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3. Results
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3.1. Operative characteristics
All patients underwent MV repair for 3+ or 4+ MV regurgitation. Seventeen patients (85%) underwent triangular resection of P2, one patient (5%) had a triple-scallops (P1, P2, P3) repair and two patients (10%) underwent a double-scallops (P2, P3) triangular resection. Operative details are reported in Table 2. The mean band size was 29.1±1.5 mm (range=28–32 mm). The mean CPB was 83.2±20.7 min (range=41–132 min). The mean cross-clamp time was 60.1±15.8 min (range=30–89 min).
3.2. Outcomes
Death within 30 days was 0%. The postoperative outcome was uncomplicated for the majority of patients (Table 3). Transient acute renal failure occurred in three patients (15%). One patient (5%) required re-exploration for bleeding. Eighteen patients (90%) were extubated by postoperative day (POD) 1 and all were discharged from the intensive care unit by the second POD. The mean postoperative length of stay was 9.2±3.4 days (range=7–21 days). All patients underwent a pre-discharge transthoracic echocardiography (TTE) and they were anticoagulated for three months with warfarin sodium.
3.3. Echocardiographic evaluation
Follow-up information was obtained during outpatient appointments. The mean duration of follow-up was 13.1±4.2 months and was 100% complete. Survival was 95%, one patient died of lymphoma during the follow-up time (Fig. 2). All the patients were in New York Heart Association (NYHA) class I; they underwent TTE (5), or TEE (13), performed by two skilled cardiologists of our team, using a 2.5 MHz ultrasound transducer (Hewlett-Packard Sonos 2500 system). The echocardiographic study consisted of a morphologic and functional analysis of the MV, focusing attention on: the grade of MV regurgitation, the length and mobility of the posterior MV leaflet (PMVL), the diameter of the mitral annulus at 0°, 60° and 90°. Follow-up echocardiographic findings are shown in Table 4. All patients (100%) showed a 0 to 1+ MV regurgitation grade.
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4. Discussion
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Despite the widely accepted benefits of MV repair over replacement in terms of early and late morbidity and mortality, only 40% of regurgitant MV, due to all causes, were repaired according to the data of the Society of Thoracic Surgeons Database [1]. In the last decade we assisted to a significant improvement in the interest about various repair techniques, even if quadrangular resection with annular plication has provided the most durable and encouraging results [5]. Earlier repair not only improves the outcome of the repair, as less of the MV apparatus is damaged, but also prevents further functional decline, preserving left ventricular geometry and function and minimizing the onset of AF and its thromboembolic and anticoagulant-related risks [7]. Suri and colleagues were the first to describe, in 2005, the concept of triangular resection for degenerative MV disease in case of anterior, posterior or bileaflet prolapse [8]. However, as with other repair, attention must be focused to reduce the risk of systolic anterior motion (SAM) [9]. Encouraged by the easier feasibility of the technique, the preliminary good results and the low rates of SAM, as demonstrated by Grossi and colleagues, triangular resection with ring annuloplasty has gradually become the procedure of choice for the surgical correction of PMVL prolapse due to myxomatous degenerative disease at our institution [10]. Our decision moved from several important benefits: (1) triangular resection minimizes the amount of resected leaflet tissue, limiting the resection to a small triangle with the base (the wider resected area) towards the leading edge of the leaflet (the most frequently diseased portion of the leaflet), lowering the danger of creating a critical decrease in MV area and the risk of technical failure at the annular level [11]; (2) the preservation of the leaflet tissue and the underlying chordae allows surgeons to achieve a more physiologic repair while still reducing the height of the diseased leaflet; (3) the reconstruction recreates a more normal posterior leaflet surface which is sufficient to obtain the elimination of the prolapse and MR. The good clinical results of this technique have been widely described by Suri et al. and Gazoni et al. in two recent studies, showing a 30-day postoperative mortality of 0% and a risk of re-operation of 0.5% per year for isolated posterior leaflet disease [5, 12]. Our study confirmed the good early results with 0% mortality rate and no complication related to the procedure. We did not observe any case of SAM immediately after repair or at follow-up. In addition to the good clinical results, our study focused attention on the anatomical and functional analysis of triangular resection of PMVL, assessed by echocardiography, in order to demonstrate the early and mid-term advantages of this more approachable technique. After a mean follow-up time of 13.1±4.2 months, the most important finding, other than the elimination of MV regurgitation in all patients, was that the technique allowed us to obtain a repaired MV with similar anatomical characteristics to the native valve: the mean PMVL length was 1.3±0.3 cm with a preserved mobility in all patients and a MV area, calculated with pressure half time P1/2t method, of 2.1±0.4 cm2, demonstrating that triangular resection preserves the physiological ‘bileaflet’ anatomy of MV, avoiding the immobility and the loss of contribution of the PMVL to the closure mechanism of the valve as it usually occurs in the other repair techniques. We, therefore, believe that triangular resection of PMVL provides the contemporary cardiac surgeon with a reliable, reproducible and teachable operation for myxomatous degenerative MV regurgitation.
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Abstract
1. Introduction
