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Eur J Cardiothorac Surg 2000;17:201-205
© 2000 Elsevier Science NL

The double-orifice technique as a standardized approach to treat mitral regurgitation due to severe myxomatous disease: surgical technique

Cardiac Surgery Department, IRRCS Ospedale San Raffaele, Via Olgettina 60, 20132 Milan, Italy

Corresponding author. Tel.: +39-2-2643-7109; fax: +39-2-2643-7125
e-mail: francesco.maisano{at}hsr.it

	Abstract

Top Abstract 1. Introduction 2. Methods 3. Surgical technique 4. Results 5. Discussion Appendix A. Conference... References

 
Objectives: Mitral-valve repair in Barlow's disease is challenging; conventional techniques are difficult to perform, and there is a high risk of a postoperative suboptimal result. Double-orifice repair has been applied in a standardized approach to treat patients with severe mitral regurgitation and bileaflet prolapse due to Barlow's disease. Methods: Since 1993, 82 patients with severe mitral regurgitation due to Barlow's disease underwent correction applying the edge-to-edge concept. They were submitted to double-orifice repair in a standardized fashion, suturing the middle portions of both leaflets. Results: There were no hospital deaths. The repair was unsatisfactory in one patient who underwent valve replacement soon after the repair. The mean postoperative valve area was 3.7±0.79 cm² against a mean preoperative value of 9.2±2.1 cm². No or mild regurgitation was found in all but three patients who showed moderate residual regurgitation. There were no late deaths. Freedom from reoperation was 86±14% at 5 years. At the latest follow-up, all patient but one were New York Heart Association (NYHA) functional class I, and echo-Doppler assessment of valve reconstruction showed stable valve function in all patients. Conclusions: The double-orifice repair can be used as a standardized approach to treat valve regurgitation due to Barlow disease with low risk and good early and mid-term results.

Key Words: Mitral regurgitation • Valve repair • Barlow's disease • Mitral-valve prolapse

	1. Introduction

Top Abstract 1. Introduction 2. Methods 3. Surgical technique 4. Results 5. Discussion Appendix A. Conference... References

 
Degenerative disease is the most common etiology of mitral regurgitation in patients undergoing mitral-valve surgery in western countries. According to Carpentier and co-workers, degeneration can be mainly classified as fibroelastic deficiency and myxomatous or Barlow's disease [1]. The central feature of the latter is the displacement of the valve leaflets in relation to the annulus, due to elongation of the subvalvar apparatus and redundant leaflet tissue [2]. The repair of the mitral valve is challenging in the severe forms of this condition because of the complexity of the three-dimensional disarrangement responsible for the valve regurgitation. Moreover, postoperative left-ventricular outflow obstruction is a potential risk. Conventional valve-repair techniques include a number of different maneuvres directed towards the shortening of the subvalvar apparatus. Both immediate and long-term results can be affected by the complexity of these maneuvres.

As an alternative method of correction we applied the edge-to-edge concept [3] in a standardized way, dedicated to Barlow's disease. Herein, we provide a description of the surgical technique and short-term results of this novel approach for valve repair in the setting of severe myxomatous disease.

	2. Methods

Top Abstract 1. Introduction 2. Methods 3. Surgical technique 4. Results 5. Discussion Appendix A. Conference... References

 
2.1. Patients
Between January 1993 and June 1999, out of 657 patients undergoing mitral-valve repair for pure mitral regurgitation, 82 patients with Barlow's disease underwent correction applying the edge-to-edge concept. The technique was applied as a standardized mode of correction for patients with severe mitral regurgitation due to bileaflet prolapse.

There were 53 male and 29 female patients, mean age was 48±13.5 years. Fifty-two patients were asymptomatic or NYHA class I at admission, 21 patients were class II, three were class III, and only two patients were class IV.

Bileaflet prolapse, the central feature of the disease, was present in all patients; in 23 patients, flail leaflet (in 20 patients the posterior) due to ruptured primary chordae contributed to the mechanism of regurgitation.

In 14 cases, the annulus was extensively calcified, with calcifications visible at plain chest X-ray.

2.2. Preoperative assessment
Diagnosis of Barlow's disease was obtained preoperatively in all patients by 2-D Doppler echocardiography. All patients underwent intraoperative, transesophageal echo-Doppler evaluation of the anatomy of the valve after the induction of general anesthesia.

Diagnostic findings present in all patients were annular dilatation, bileaflet thickening and redundancy with billowing and prolapse, reduction of the coaptation area with level of coaptation above the annular plane, elongation of the subvalvar apparatus and hypertrophied papillary muscles. At Doppler echocardiography, multiple regurgitant jets were present in 65 patients (79%) as a consequence of complex and multiple mechanisms of regurgitation.

Cardiac catheterization was carried out in all male patients and in females older than 45 years to exclude coronary artery disease. Left-ventricular angiography identified patients with severely calcified annulus.

	3. Surgical technique

Top Abstract 1. Introduction 2. Methods 3. Surgical technique 4. Results 5. Discussion Appendix A. Conference... References

 
Mitral-valve repair was performed during total normothermic cardiopulmonary by-pass, through a conventional midline sternotomy. In seven patients, the repair was carried out through a limited lateral thoracotomy for cosmetic reasons. Myocardial protection was accomplished by antegrade cold-blood cardioplegia; retrograde cardioplegia was associated in cases of significant aortic regurgitation.

The mitral valve was accessed through the left atrium, after development of the interatrial groove.

An intraoperative inspection of the valve was carried out to confirm preoperative echocardiography findings and to identify any additional lesion. Typically, the valve leaflets appeared severely diseased, dismorphic and thickened. Several clefts were almost always present on the free edge of the anterior leaflet, particularly on the paracommissural segments. Although these clefts are usually not deep, they strongly interfere with the coaptation and should be closed primarily.

Annular dilatation and deformation were always severe, annular calcification was present usually in the site underlying the most diseased segment of a leaflet.

The subvalvar apparatus was usually redundant with hypertrophied papillary muscles and thickened chordae tendinee.

3.1. The double-orifice technique
The middle portion of the leaflets is identified by subvalvular inspection with a nerve hook. Chordae connected to the anterolateral and posteromedial papillary muscles are identified, and the middle portion of the leaflet is defined as the zone of convergence of the two groups of chordae (Fig. 1). A stay stitch is placed in the middle portion of the free edge of both leaflets with a polypropylene 4-0 suture; this suture is subsequently used to complete the edge-to-edge repair (Fig. 2). Using this stay stitch, the symmetricity of the two halves of the valve is checked again to avoid postoperative distortion and residual leakage.

View larger version (18K): [in this window] [in a new window]   Fig. 1. Subvalvar apparatus inspection with a nerve hook. (*) The middle portion of the leaflets is identified.

View larger version (9K): [in this window] [in a new window]   Fig. 2. The central stitch is used to check the symmetricity of the orifices.

Repair is then completed by suturing the whole free edge of the medial segments of the anterior and posterior leaflets with a running 4-0 polypropylene suture (Fig. 3). Big bites of leaflet tissue should be taken with this suture to give strength to the repair and to reduce the leaflet height in the middle of the double-orifice valve (Fig. 4). The running suture length is variable, but commonly it covers the whole length of the medial scallop of the posterior leaflet (P2) in a standardized manner. A shorter suture should be used in patients with smaller valves.

View larger version (14K): [in this window] [in a new window]   Fig. 3. A running suture along the free edge of the leaflets is done.

View larger version (15K): [in this window] [in a new window]   Fig. 4. Deep bites through the rough zone of the leaflets are placed to avoid tearing of the suture.

3.2. Associated procedures
In eight patients, a quadrangular resection of the posterior leaflet was performed. We associated the resection of the posterior leaflet in cases of extreme thickening of the leaflet, or in cases of extensive prolapse with bulking tissue potentially interfering with the hemodynamics of the corrected valve.

Another associated procedure in this series was cleft correction, either of the posterior or anterior leaflets (four patients).

In three patients, prolapse of the commissural area was repaired by paracommissural edge-to-edge repair. Following this maneuver, residual valve area was assessed to exclude the risk of creating a stenotic valve.

3.3. Annuloplasty
An annuloplasty procedure was routinely performed in 75 patients to reshape and reduce the annular orifice. A semi-rigid Seguin Ring (St. Jude Medical^TM) was used in 52 patients, a standard Carpentier Ring (Baxter^TM) in 13 patients and posterior autologous pericardium plasty was performed in eight patients. No annuloplasty was carried out in eight patients with extensively calcified annulus.

At the end of the procedure, the valve orifices were measured by introducing Hegar dilators to each orifice, and the competence was assessed by saline injection into the left ventricle.

After weaning from cardiopulmonary by-pass, transesophageal echo-Doppler reassessment of the valve was performed with the calculation of planimetric area, Doppler-derived effective orifice area, transmitral flows and competence analysis.

	4. Results

Top Abstract 1. Introduction 2. Methods 3. Surgical technique 4. Results 5. Discussion Appendix A. Conference... References

 
There were no hospital deaths. Aortic cross-clamp time was 38±12 min, and cardiopulmonary by-pass time was 51±19 min. In one patient, the total valve area measured with Hegar dilators was less than 2.0 cm²; consequently, valve replacement was performed. None of the remaining patients had postoperative mitral stenosis. The mean postoperative valve area, assessed by transesophageal Doppler echocardiography, was 3.7±0.79 cm² (against a mean preoperative value of 9.2±2.1 cm²).

Postoperatively, no or mild regurgitation was found in all but three patients, who showed moderate residual regurgitation (all of them had a severely calcified and dilated annulus). Follow-up was complete, and ranged from 1 month to 5 years (mean follow-up: 1.3 years, 113 patient-years). Follow-up information was obtained at outpatient visit or by telephone interview. All patients were requested to be submitted to Doppler echocardiography prior to follow-up interview.

There were no late deaths. One patient required late (3 years after the first operation) reoperation for acute endocarditis and underwent successful valve replacement. Freedom from reoperation was 86±14% at 5 years. During the follow-up period, one patient suffered a thromboembolic event for an an overall freedom from all cardiac events of 79±15% at 5 years. At the latest follow-up, all patients but one (who is moderately symptomatic) were NYHA functional class I. The patients with moderate mitral regurgitation were asymptomatic. Moreover, echo-Doppler assessment of valve reconstruction (obtained in 75 patients) showed stable valve function in all patients, without signs of progression of valve regurgitation or reduction of effective orifice area (Fig. 5).

View larger version (18K): [in this window] [in a new window]   Fig. 5. Echo-Doppler assessment: mitral-regurgitation grade and valve area. MR, mitral-regurgitation grade as a mean area obtained either by planimetric assessment or by pressure half-time method.

	5. Discussion

Top Abstract 1. Introduction 2. Methods 3. Surgical technique 4. Results 5. Discussion Appendix A. Conference... References

We applied a simple technique which corrects mitral regurgitation, acting at leaflet level with no need for intervention on the subvalvar apparatus. The double-orifice technique is effective in correcting the mitral regurgitation through a single mechanism: the forced coaptation in the middle of the leaflet. The edge-to-edge technique reduces the height of the leaflets in their middle portion and lowers the level of coaptation below the annulus.

The combined annuloplasty increases the coaptation surface without affecting the global orifice area.

A reduction of the global postoperative area of the mitral valve is the major drawback of the procedure. In a previous paper, we demonstrated, through a fluidodynamic model of the double-orifice mitral valve, that the performance of the valve is comparable with that of a single-orifice valve of the same global area [5]. The hemodynamics are not affected by the asymmetry between the two orifices, and the velocities through the orifices are similar, allowing the application of Doppler methods for hemodynamic evaluation. However, the creation of a double-orifice valve determines a significant reduction of the global area, up to 60% of the basal one. Such a reduction might be a disadvantage when the technique is applied on valves without annular dilatation, while it has never been a problem in the setting of Barlow's disease.

Leaflet redundancy, especially of the posterior leaflet, predisposes to postoperative left-ventricular outflow obstruction due to systolic anterior movement (SAM) of the anterior leaflet when conventional techniques of repair are applied in Barlow's disease. Sliding plasty of the posterior leaflet is necessary to reduce this risk [6]. The double-orifice technique abolishes the risk of SAM by fixing the free edge of the anterior leaflet in the area usually responsible for this phenomenon.

The technique provides a safe and predictable result by a simple and standardized procedure. This feature is essential to intervene in an early phase of the disease as there is evidence of a beneficial effect of early surgery on both survival and freedom from adverse events following an early intervention strategy in patients with flail leaflets [7].

The double-orifice repair and the annuloplasty act synergically to correct mitral regurgitation in Barlow's disease. The double-orifice repair restores the coaptation level for both leaflets, however, annuloplasty is necessary to increase the area of coaptation. We recommend an annuloplasty in all patients with Barlow's disease, preferably with a prosthetic ring, to correct the severe deformation. This combined approach not only restores a competent valve, but decreases the stress on the leaflet surface, reducing the risk of long-term degeneration and chordal rupture. However, the long-term results of this technique are still undetermined, and its application should be reserved to clinical and anatomical circumstances when conventional techniques are either not reproducible or too complex to perform.

	Footnotes

 
Presented at the 13th Annual Meeting of the European Association for Cardio-thoracic Surgery, Glasgow, Scotland, UK, September 5–8, 1999.

	Appendix A. Conference discussion

Top Abstract 1. Introduction 2. Methods 3. Surgical technique 4. Results 5. Discussion Appendix A. Conference... References

 
Dr G. Dreyfus (Suresnes, France): I do think that the so-called Alfieri stitch is a very clever solution for restricted leaflet motion, in which sometimes you cannot achieve a good coaptation with a simple ring. However, when there is a leaflet prolapse such as in Barlow disease, I do not really understand how you can achieve coaptation just by suturing. You said that in one of your slides. How can you lower the coaptation point by suturing the anterior leaflet to the posterior leaflet, as the prolapse is not due to the leaflet but mainly due to elongated chordae or papillary muscle. So I do not really understand how you can achieve that.

I would like you also to comment on the long-term results, because we all know that mitral-valve repair has gained confidence and reliability because it has shown that results were stable throughout time beyond 12 or 16 years. You show results with about 4 years’ follow-up. Don't you believe that this technique will show increased failure with time?

Dr Maisano: Regarding the first question, in Barlow disease there is evidence for the elongation of both the subvalvar apparatus and the leaflet height. Most probably, with the double-orifice technique, when you suture the leaflet edges, you shorten the leaflet height and obtain the lowering of the point of coaptation. However, this concept needs to be confirmed by specifically designed investigation.

Regarding the long-term results, these are not available at the moment, since the technique has been introduced just a few years ago. However, from the follow-up data we have obtained up to now, the results are very stable, patients do well and we expect good results also in the long-term. The issue is another one: these valves are very complex to repair, and probably not all the surgeons can repair them with predictable and acceptable results. As we showed, we are treating the most severe forms of Barlow disease which are very difficult to manage for the tremendous three-dimensional and structural abnormalities they show. So the question is: should we repair these valves or replace them? Once you are facing one of these valves, we believe it is better to proceed with a simple and safe repair procedure associated with predictable results, than to carry on a complex procedure that may end up with a suboptimal repair, influencing the long-term results as well.

Dr O. Oto (Izmir, Turkey): I just wonder how you predict the postoperative mitral-orifice area in order to make the decision to use this technique preoperatively or not?

Dr Maisano: Yes. The postoperative area is reduced about 50–60% than the preoperative one. I would like to stress this point: we think that this procedure works very well in the most severe forms of Barlow disease. In this case, the preoperative area is around 10 cm². After the repair, 3.6 is our mean postoperative area.

Dr F. Van der Veen (Maastricht, The Netherlands): I am very curious to know whether the repair also has any effect on left-ventricular function, as you have very nicely measured with the conductance catheter?

Dr Maisano: We are now running a program with the conductance catheter to assess left-ventricular function. The number of patients who underwent this study is too low to elaborate any influence from it. I don't think there will be any difference between this procedure and other procedures in terms of post-operative ventricular function. The only thing I can say is that this operation can be done in a very short cross-clamp time, and this can be very beneficial in patients with depressed left-ventricular function.

	References

Top Abstract 1. Introduction 2. Methods 3. Surgical technique 4. Results 5. Discussion Appendix A. Conference... References

 

1. Carpentier A., Chavaud S., Fabiani F.T., Deloche A., Relland J., Lessana A., d'Allaines C., Blondeau P., Piwnica A., Dubost C. Reconstructive surgery of mitral valve incompetence. Ten year appraisal. J Thorac Cardiovasc Surg 1980;79:338-348.[Abstract]
2. Weissman N.J., Pini R., Roman M.J., Kramer Fox R., Andersen H.S., Devereux R.B. In vivo mitral valve morphology and motion in mitral valve prolapse. Am J Cardiol 1984;73:1080-1088.
3. Maisano F., Torracca L., Oppizzi M., Stefano P.L., D'Addario G., La Canna G., Zogno M., Alfieri O. The edge-to-edge technique, a simplified method to correct mitral insufficiency. Eur J Cardio-thorac Surg 1998;13:240-246.[Abstract/Free Full Text]
4. Carpentier A. Cardiac valve surgery - the ‘French correction’. J Thorac Cardiovasc Surg 1983;86:323-337.[Medline]
5. Maisano F., Redaelli A., Pennati G., Fumero R., Torracca L., Alfieri O. The hemodynamic effects of double-orifice valve repair for mitral regurgitation: a 3-D computational model. Eur J Cardio-thorac Surg 1999;15:419-425.[Abstract/Free Full Text]
6. Jebara V.A., Mihaileanu S., Acar C., Brizard C., Grare P., Latremuille C., Chavaud S., Fabiani J.N., Deloche A., Carpentier A. Left ventricular outflow tract obstruction after mitral-valve repair - results of the sliding leaflet technique. Circulation 1993;88 (Part 2):30-34.
7. Ling L.H., Enriquez-Sarano M., Seward J.B., Orszulak T.A., Shaff H.V., Bailey K.R., Tajik A.J., Frye R.L. Early surgery in patients with mitral regurgitation due to flail leaflets. A long-term outcome study. Circulation 1997;96:1819-1825.[Abstract/Free Full Text]

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