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Eur J Cardiothorac Surg 1999;14:274-278
© 1999 Elsevier Science NL

Less invasive approaches for closed mitral commissurotomy¹

Esat Aknc^a, Muzaffer Deertekin^b, Mustafa Güler^a, Bahadr Dalar^a, Nilgün Bozbua^a, Turan Berki^a, Cevat Yakut^a

^a Department of Cardiovascular Surgery, Kouyolu Heart and Research Hospital, stanbul, Turkey
^b Department of Cardiology, Kouyolu Heart and Research Hospital, stanbul, Turkey

Received 28 September 1997; received in revised form 18 May 1998; accepted 9 June 1998.

Corresponding author. Kouyolu Kalp ve Aratirma Hastanesi (Kouyolu Heart and Research Hospital), Kadiköy, stanbul, 81020 Türkiye. Tel.: +90 216 325 54 57; fax: +90 216 33904 41; e-mail: eakinci@superonline.com

	Abstract

Top Abstract Introduction Patients and methods Transesophageal examination Surgical technique Results Discussion Appendix A. Conference... References

 
Objective: Recently, closed mitral commissurotomy (CMC) has been reexplored due to the concepts of less invasive valvular surgery. The feasibility of closed mitral commissurotomy via port access (or limited thoracotomy) by aid transesophageal echocardiography (TEE) was investigated in this clinical study. Methods: Between August 1996 and April 1998, 42 patients (32 women, ten men with a mean age of 36.2±7.8 years) underwent less invasive CMC at the Kosuyolu Heart and Research Hospital. CMC procedure were done through a limited (12–16 cm) thoracotomy incision in 23 patients, a very limited or mini thoracotomy incision (7–8 cm) in 11 patients and port access by aid TEE in eight patients. Preoperative mean mitral valve area was calculated as 1.19±0.13 cm² and mean mitral valve gradient was measured as 14.8±3.2 mmHg. TEE provided information about the mitral valve anatomy and functions during the procedure in all patients. Results: Commissurotomy was successfully performed in all patients. In eight patients, a Tubbs dilator was inserted via port access at the 6th intercostal space from a 3-cm incision. Incision by guidance of TEE and CMC could be performed without thoracotomy in five patients. In three patients of the port access group, a very limited thoracotomy was required to perform CMC by digital guidance. Postoperative mean MVA was 2.37±0.29 cm², minimal mitral gradient was 5.3±1.7 mmHg. In eleven patients, minimal mitral regurgitation was observed. The operations and postoperative period were free of complications in all patients. Following an average 12±2.8 h intensive care unit period, all patients were discharged after an average of 3.4±0.8 days of hospitalization. Conclusion: Limited thoracotomy has less detrimental structural effects in patients. Port access by aid TEE approach to CMC may offer less invasiveness, lower cost effectiveness and be an alternative to percutaneous balloon mitral valvotomy.

Key Words: Closed mitral commissurotomy • Minimal invasive valve surgery • Port access closed mitral commissurotomy • Transesophageal echocardiography

	Introduction

Top Abstract Introduction Patients and methods Transesophageal examination Surgical technique Results Discussion Appendix A. Conference... References

 
Closed mitral commissurotomy (CMC) was the first effective intervention in valvular heart disease. The possibility of opening a stenotic mitral valve by digital splitting of the fused commissures was apparently suggested by Samways as early as 1898 [1]. Standard CMC still remains popular, mostly in developing countries since it does not have different results other than open mitral commissurotomy (OMC) and, has similar long-term restenosis and reoperation incidences [2] [3]. Meanwhile, more efforts have been made to introduce new techniques in minimal invasive valve surgery. Recently, CMC has been reexplored due to the concepts of less invasive valvular surgery. The feasibility of closed mitral commissurotomy via port access or through limited thoracotomy by aid transesophageal echocardiography (TEE) was investigated in this clinical study.

	Patients and methods

Top Abstract Introduction Patients and methods Transesophageal examination Surgical technique Results Discussion Appendix A. Conference... References

 
Between August 1996 and April 1998, surgical treatment was performed in 487 patients with isolated mitral valve disease at the Kosuyolu Heart and Research Hospital. Our surgical policy in mitral stenosis is to perform the open radical mitral commissurotomy in most of the cases to achieve optimal subvalvular apparatus releasing. Forty-two cases with pure non-calcific stenosis (8.83%) were suitable for closed mitral commissurotomy.

The criteria for suitability of CMC were pure mitral stenosis, a pliable mitral valve apparatus with mobile leaflets, absence of classification of leaflets or annulus, absence of left atrial thrombus and, and appropriate subvalvular apparatus of the mitral valve.

Between August 1996 and April 1998, 42 patients (32 women, ten men with a mean age of 36.2±7.8 years) underwent less invasive CMC at the Kosuyolu Heart and Research Hospital. The electrocardiograms revealed normal sinus rhythm in 28 patients and atrial fibrillation in 14 patients. The patients characteristics are presented in Table 1.

	Transesophageal examination

Top Abstract Introduction Patients and methods Transesophageal examination Surgical technique Results Discussion Appendix A. Conference... References

TEE provided information about the mitral valve anatomy and functions during the procedure in all patients. During CMC procedure, the introduction of the Tubbs dilator through the cordae and the advancement of the Tubbs dilator in the proper position into the mitral leaflets could be documented properly ( Fig. 1 ) and checked by four chamber and transgastric TEE images. Therefore, the guidance protocol was successfully performed with or without digital guiding. Mitral valve area (MVA) was measured by pressure half-time (PHT) and planimetry (PLN) methods (Table 2). Mitral regurgitation was performed and graded by color Doppler echocardiography. Separations of the mitral commissures were observed by transgastric short axis approach and appearance of separation was commended to be a success. TEE also provided information about the mitral valve anatomy after the dilatation procedure.

View larger version (86K): [in this window] [in a new window]   Fig. 1. Tubb's. The appearance of Tubbs dilator through the mitral leaflets.

	Surgical technique

Top Abstract Introduction Patients and methods Transesophageal examination Surgical technique Results Discussion Appendix A. Conference... References

	Results

Top Abstract Introduction Patients and methods Transesophageal examination Surgical technique Results Discussion Appendix A. Conference... References

 
There was no mortality. Ventricular fibrillation occurred in two cases and was managed successfully by electrical defibrillation during the procedure. Adequate mitral valve area was achieved in all patients. There was no thromboembolic event. Any kind of surgical complication such as bleeding, ventricular or atrial rupture, and acute mitral insufficiency was not encountered.

Commissurotomy was successfully performed in all patients. In eight patients, Tubbs dilator was inserted via port access at the 6th intercostal space from a 3 cm incision. Incision by guidance of TEE and CMC could be performed without thoracotomy in five patients. In three patients of the port access group, a very limited thoracotomy was required to perform CMC by digital guidance. In six cases, introduction of the Tubbs dilator in the appropriate position was achieved without using index finger guidance by TEE. CMC could be performed without thoracotomy in five patients. In one patient, the placed Tubbs dilator could not be stabilized between leaflets and could not provide sufficient mitral valve opening. In two patients of the port access group, the Tubbs dilator could not be placed between the leaflets and a very limited thoracotomy was required to perform CMC by digital guidance.

After the CMC procedure, the parameters (mitral valve area, mean mitral gradient, mitral regurgitation, excursion of the leaflet) were obtained. Left atrial appendicial SEC, chordal rupture were detected. Separation of mitral commissures was measured ( Fig. 2 ).

View larger version (80K): [in this window] [in a new window]   Fig. 2. Commisssural separation. Transgastric short axis view of mitral leaflets, valve area and commissural separation.

Intraoperatively transesophageal echocardiography was performed in 42 patients without any complication. Mitral valve area were determined in 36 (85%) of 42 patients by PHT and 34 (80%) of them by PLN methods. The mean postoperative mitral valve area was 2.41±0.32 cm². The measured mean preoperative mitral valve gradient was 14.8±3.2 mmHg, and the postoperative valve gradient was 5.3±1.7 mmHg (P<0.05). In 14 patients (33%), minimal mitral regurgitation was detected. SEC images which were seen preoperatively in 17 (40%) patients disappeared. Chordal rupture was not seen (Table 2). Commissural separation was obtained in all patients who had sufficient transgastric echocardiographic images.

The mean intensive care unit (ICU) surveillance was 12±2.8 h. Mean hospitalization period was 3.4±0.7 days. Thirty-two (76%) of the patients were in NYHA functional class I, eight (19%) in class II, and two (5%) in class III postoperatively. All of the patients are living an active life.

	Discussion

Top Abstract Introduction Patients and methods Transesophageal examination Surgical technique Results Discussion Appendix A. Conference... References

 
Three alternative methods, OMC and closed mitral commissurotomy and percutaneous balloon mitral valvotomy (PBMV), have been presented in the surgical treatment of pure mitral stenosis. Although OMC provides the best conditions for surgical treatment of pure mitral stenosis, it has disadvantages such as the necessity of sternotomy and cardiopulmonary bypass. It has been stated that OMC is not superior to CMC in accordance with cardiac performance, thrombo-embolic event, functional status, reoperation risk and long-term results [3].

As the least invasive method, PBMV has many complications such as cardiac perforation (0–4%), left to-right shunting at the atrial level due to dilatation of atrial septal puncture (35%). Rarely the defect is large enough to cause right heart failure [4] [5] [6]. Systemic arterial hypotension may occur due to transient occlusion of left ventricular inflow during balloon inflation [7]. In addition all patients are exposed to radiation during the procedure.

Since there is no significant differences between the results of each of the three methods, there is a tendency to choose the lesser invasive and lower cost method. The idea of performing the CMC procedure with much smaller thoracotomy incision has been accepted due to the concepts of less invasive valvular surgery. As the learning curve increased, this procedure could be performed with more limited incision, so the thoracotomy incision was decreased to nearly 8 cm and then to only 3 cm. Meanwhile, in unsuccessful cases, it was possible to perform anterolateral limited thoracotomy immediately in order to perform conventional CMC.

The other important point is that TEE seems to have a new application area in cardiac surgery. Stoddard et al. have shown that measurement of mitral valve area by TEE using the PHT method correlates well with transthoracic measurements [8]. However, the sudden changes in atrioventricular compliance and transmitral pressure gradient that accompany acute valvotomy might effect the accuracy of the PHT method. In our study, we found great differences between pre- and post-operative PHT measurements and mitral valve areas. Additionally, we did not determine the accomplishment of CMC only by PHT results. MVA was also determined by transgastric images, using the PLN method. Although the application of the PLN method by monoplane or biplane TEE could be performed in 40–60% of the patients, we measured MVA in 81% of patients by using a multiplane TEE probe [9] [10].

Tubbs dilator was imaged in all of the procedures. In the port access method, Tubbs dilator was not progressed into the left atrium in patients with severe mitral stenosis. This showed that, the port access method had a limitation in patients with <0.8 cm² MVA. Disappearing of SEC confirmed by TEE was observed in all cases in which mitral valve pleability increased, mitral commissural separation was succeeded, and view quality was good.

TEE guided CMC by limited thoracotomy attempts not only to eliminate adverse effects of CPB, but also to decrease incidence of pulmonary complications and wound infections. By performing this technique intensive care unit period reduced and earlier ambulation could be achieved.

Although this procedure is to be performed under general anesthesia, it is obvious that it will be an alternative to PBMV in accordance with invasiveness. With concerning port access CMC is less invasive than PBMV, and has low cost effectiveness, and does not carry the same risk of potential complications as PBMV. It seems to be a more wiser solution to the pure mitral stenosis.

	Footnotes

 
Presented at the 11th Annual Meeting of the European Association for Cardio-thoracic Surgery, Copenhagen, Denmark, September 28 – October 1, 1997.

	Appendix A. Conference discussion

Top Abstract Introduction Patients and methods Transesophageal examination Surgical technique Results Discussion Appendix A. Conference... References

 
Dr O. Oto (Izmir, Turkey): Really, this study, I believe, will bring many advantages to cardiac surgery in many aspects. One of them is we may regain a subject that we have lost to cardiologists with balloon angioplasty. In the past, closed mitral valvotomy was a very common procedure in cardiac surgery. And secondly, the economic advantage of this procedure is really marvelous. I also believe that this can be done totally endoscopically in the future and also this can be done with smaller incisions, as well.

Dr J. Svennevig (Oslo, Norway): May I just ask you about a technical matter. I mean this method was in use in most, if not all, European hospitals some years ago, but I don't think that too many hospitals still perform open or closed mitral commissurotomy in the way you do. Did you use the Tubbs dilator in all cases, or do you sometimes only use the tip of the finger?

Dr Akinci: We use finger examination only for guiding Tubbs, for some cases. We generally evaluated the mitral valve by echo.

Dr S. Keshk (Alexandria, Egypt): We practiced this technique 3 months ago, so we have a very short experience. But I found in cases where the mitral valve area is too small, for example, if it is 0.6 cm², it is too difficult to guide the Tubb through the process of the echocardiogram because the opening is too small to introduce the Tubb. And so we spend a lot of time trying to push the Tubb through this small opening. So I think that this technique is good, but you must have good selection of patients.

Dr Akinci: I agree with you. We generally prefer open mitral commissurotomy and reconstruction for mitral stenosis, but in selected patients this technique could be performed. Patient selection is the most important point in the study as I mentioned before.

Dr D. Saksena (Bombay, India): I would just like to make a comment rather than ask a question. We all realize, the surgeons who have grown up in the earlier years, that closed mitral commissurotomy was an excellent operation with good long-term results. And I congratulate the young investigators for bringing it again to the attention of an audience at a time when cost is becoming of paramount importance. As was mentioned, with a smaller incision you can do it, and the cost of the closed mitral commissurotomy as practiced in large parts of the world comes to less that $US 50, because there is no disposable material involved, there is nothing involved, it is just a piece of prolene that you need to tie the atrial appendage. So the cost is the major thing. It is a good operation, and it should be revived wherever there is a need for this kind of procedure. And I congratulate the author again for bringing it to the attention of the Society.

Dr M.A. Mohamed: Dr. Akinci used Tubbs dilator through ventriculotomy but he did not show us how he closed that ventriculotomy, and the operation was via minithoracotomy so if he closed it through that small incision, does that occur without any complications like bleeding or arrhythmias.

Dr Akinci: There were no complications. As I mentioned, we used simple a pursestring for the left atrial appendage and for the left ventricle apex.

Dr Svennevig: So you agree that we should not hand over these problems to the cardiologists, we should reestablish the technique. Do you think even in elderly patients?

Dr Akinci: Yes.

Dr Svennevig: Do you think it could work even in the old patients with the more calcified mitral valves? Because your patients are very young, you have a mean age of 38 years, and I cannot remember the last time I saw a pure mitral stenosis in a 38-year-old patient. Do you think it could work in the old patients? Do you think that this technique could be used in the very old, high-risk patients?

Dr Akinci: No, in the all patients the age was generally young.

Dr Oto: I believe that even balloon angioplasty cannot apply to the high-risk patients, as you mentioned, like highly calcified mitral valves. So if you consider the indication for balloon valvotomy and closed commissurotomy, then there is no disadvantage to this procedure, I believe. In those patients who have calcified mitral stenosis, obviously open mitral commissurotomy is the first choice.

Dr R. Landymore (Riyadh, Saudi Arabia): The patients with mitral stenosis in Saudi Arabia are often between the ages of 20 and 30 years. The patients that you have described would be treated in our cardiac catheterization laboratory with balloon valvotomy. In other words your patients have pure mitral stenosis, very little mitral insufficiency, no calcification of the mitral valve, an no involvement of the sub-valvular apparatus. We would elect to treat these patients with balloon valvotomy because we know that these patients will require operation within the next 10 years. These young patients appear to have a very aggressive disease and tend to develop sub-valvular pathology. Do you operate upon all your patients because operation is more cost effective or are some of these patients still managed in the cardiac catheterization laboratory with the less invasive approach?

Dr Svennevig: Would you comment on that? So the main reason for doing this operation, is cost reduction or is it the easiness and the simplicity of the method? What is the main reason that you prefer this method over other methods?

Dr Akinci: There was no significant difference regarding cardiac performance, functional studies, thromboembolic event and reoperation risk.

Dr Svennevig: Risk, yes, but what about cost? Is the cost, the economy of the procedure, a major factor for you in choosing this operation?

Dr Akinci: Cost-effectiveness is most important for our country. And I show in the slide –

Dr Svennevig: Thank you. I think that is a clear answer to a clear question.

	References

Top Abstract Introduction Patients and methods Transesophageal examination Surgical technique Results Discussion Appendix A. Conference... References

 

1. Samways D.W. Cardiac peristalsis: Its nature and effects. Lancet 1898;1:927.
2. Farhat M.B., Bonssadia H., Gandjbakhch I. Closed versus open mitral commissurotomy in pure non-calcific mitral stenosis: hemodynamic studies before and after operation. J Thorac Cardiovasc Surg 1990;99:639.[Abstract]
3. Hickey M.S.J., Blackstone E.H., Kirklin J.W. Outcome probabilities and life history after surgical mitral commissurotomy: implications for balloon commissurotomy. J Am Coll Cardiol 1991;17:29.[Abstract]
4. Kirklin J.W. Percutaneous balloon versus surgical closed commissurotomy for mitral stenosis. Circulation 1991;83:1950-1951.
5. L'Epine Y., Drobinsk G., Sotirov Y., et al. Right heart failure due to an inter-atrial shunt after percutaneous mitral balloon dilatation. Eur Heart J 1989;10:285.[Abstract/Free Full Text]
6. Tuzcu E.M., Block P.C., Palacios I.F. Comparison of early versus late experience with percutaneous mitral balloon valvuloplasty. J Am Coll Cardiol 1991;17:1121.[Abstract]
7. Levine M.J., Weinstein J.S., Diver D.J. Progressive improvement in pulmonary vascular resistance after percutaneous mitral valvuloplasty. Circulation 1989;79:1061.[Abstract/Free Full Text]
8. Stoddard M.F., Prince C., Tuman W.L., Wagner S.G. Angle of incidence does not affect accuracy of mitral stenosis area calculation by pressure half time: application to Doppler transesophageal echocardiography. Am Heart J 1994;124:1562-1572.
9. Stoddard M.F., Prince C., Ammash N., Goad J. Two-dimensional transesophegeal echocardiograpic determination of mitral valve area in adults with mitral stenosis. Am Heart J 1994;127:1348-1353.[Medline]
10. Davison M.B., Cohen G.I., Marwick T.H., et al. The frequency of acquisition and quality of images obtained by transesophegeal echocardiography. A prospective study of 100 consecutive cases. J Am Soc Echocardiogr 1991;4:288.

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