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Eur J Cardiothorac Surg 2002;21:447-452
© 2002 Elsevier Science NL
Cardiac Surgery Department, Hôpital Européen Georges Pompidou, Paris University, 21 rue Leblanc, 75908 Paris cedex 15, France
Received 5 October 2001; received in revised form 13 December 2001; accepted 19 December 2001.
* Corresponding author. Tel.: +33-1-5609-3624; fax: +33-1-5609-2219
e-mail: jean-michel.grinda{at}egp.ap-hop-paris.fr
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Abstract |
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 Top Abstract 1. Introduction2. Patients and methods3. Results4. DiscussionReferences |
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Key Words: Valvular disease • Rheumatic disease • Valvular surgery • Reconstructive valvular surgery
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1. Introduction |
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TopAbstract1. Introduction2. Patients and methods3. Results4. DiscussionReferences |
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2. Patients and methods |
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TopAbstract1. Introduction2. Patients and methods3. Results4. DiscussionReferences |
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2.2.1. Mitral valve diseases
Sixteen patients had mitral valve insufficiency (grade III=5, grade IV=11); seven of them had an associated mitral stenosis. Most of the patients with mitral valve insufficiency had mitral annulus deformation with restriction of the posterior leaflet and some prolapse of the anterior leaflet (type II ant, III post), which are the most common mitral dysfunctions encountered in the young rheumatic patient. Five patients had pure mitral stenosis (mean transmitral gradient=12±4 mmHg).
2.2.2. Aortic valve disease
All patients had type III aortic insufficiency (grade II=2, grade III=9, grade IV=10) due to aortic cusp retraction resulting in central triangular coaptation defect on echocardiography.
2.2.3. Tricuspid valve disease
Eight patients had an organic tricuspid valve disease resulting in type III tricuspid valve insufficiency (grade III=4, grade IV=4), and 13 patients had a functional type I tricuspid valve insufficiency (grade III=3, grade IV=10).
2.3. Surgical procedure
The operative procedures are summarized in Table 2.
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Techniques used to achieve mitral valve repair were: prosthetic mitral annuloplasty using Carpentier rings in 16 patients (the size of which were no. 26=1, no. 28=7, no. 30=6, no. 32=2), commissurotomy (12 patients), chord transposition from posterior to the anterior leaflet or secondary chord transposition to the free anterior leaflet edge (11 patients), chord shortening (four patients), papillary muscle sliding plasty (four patients), pericardial patch enlargement of the posterior mitral leaflet (four patients) or of the anterior mitral leaflet (two patients).
Aortic repair was then attempted. Three rectangular strips, the height of which was 8 mm with length adjusted according to the length of each aortic free edge cusp, were tailored in the previously harvested pericardium. Each autologous pericardial strip was then sutured to the corresponding free edge of the aortic cusp using 7-0 prolene. Starting at the midpoint of the cusp, the suture was prolonged at the commissure, onto the aortic wall, and finally stopped outside with the thread used for the adjacent cusp. The new commissures were then elevated to the height of the autologous pericardial strip (8 mm) (Fig. 1) . The aorta was sutured without any distortion so as not to disturb the architecture of the aortic valve reconstruction.
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3. Results |
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TopAbstract1. Introduction2. Patients and methods3. Results4. DiscussionReferences |
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3.2. Mortality
A 14-year-old child in preoperative NYHA Class IV died because of multi-organ failure (MOF) on postoperative day 27 (operative mortality: 4.7%).
3.3. Morbidity
Hospital complications included: MOF syndrome (n=1), low cardiac output (n=2), pneumothorax (n=1), septicemia (n=1). Mean postoperative ICU stay was 2.4±4 days (range 1–19 days).
3.4. Echocardiograms
Before 1998, intraoperative TEE was only available in patients weighing more than 30 kg, and from 1998 TEE was available in all patients. However, all of the patients underwent TTE control before discharge. Five patients had no more than grade I residual aortic insufficiency; mean postoperative gradient on the aortic extended valve was 8.2±3.7 mmHg. Seven patients had no more than a grade I mitral insufficiency; no patient had no more than grade I tricuspid valve insufficiency on control.
3.5. Follow-up
All of the surviving patients went back to their countries after surgery. In each country, one referring local physician or cardiologist was able to assess the patient's condition on the basis of physical examination and, depending on technical possibility, on the basis of TTE. In such conditions we cannot provide a uniform TTE follow-up protocol as we would have liked. One patient was lost from follow-up because of political instability in his country. Mean follow-up was 51±31 months (range 1–92 months).
3.6. Late death
No patient died during follow-up.
3.7. Redo surgery
Two patients underwent valvular redo surgery during follow-up. These two patients had pericardial patch enlargement of the anterior mitral leaflet during initial repair due to a high degree of leaflet thickening and retraction. They had significant progression or reactivation of rheumatic disease. An 11-year-old male child had a significant progression of rheumatic disease responsible for mitral and aortic valvuloplasty deterioration. He underwent an aortic homograft replacement and two unsuccessful mitral repairs before prosthetic mitral valve replacement during postoperative month 14. In the second, a 16-year-old male child, a redo mitral plasty associated with aortic homograft procedure was attempted. Because of redo mitral valvuloplasty unfeasibility, a double prosthetic valve replacement was successfully performed during postoperative month 32.
3.8. Anotomopathology of the extended aortic valve
The explanted native aortic cusp and pericardial patches were studied, including histologic studies with hematoxylin-eosin-safran, blue alcian and orceine colorations for the nucleus, cytoplasm and conjunctive tissues, respectively, and for mucopolysaccharide and elastic fiber. In the first patient, only orceine coloration allowed distinction between native aortic cusp and pericardial patches in severe sclerosis with important neovascularization and mononuclear inflammatory infiltration. In the second patient, the aortic reparation architecture was conserved. Native cusp, suture and patches were clearly distinguishable (Fig. 2)
. Aortic cusp showed chronic rheumatic process. Patches showed moderate retraction, fibrosis and rare small calcifications. The pericardium contained very few spindle cells of fibroblast appearance with abundant extracellular matrix. No endothelial layer was observed covering the surface of the pericardium
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3.10. Echocardiograms
The 17 patients present at follow-up with triple valve repairs underwent TTE in their country.
Three patients experienced deterioration in the quality of the valve repairs, during postoperative months 37, 48 and 58, respectively. All had moderate deterioration of mitral and aortic repair responsible for grade II mitral and aortic valve regurgitation.
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4. Discussion |
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TopAbstract1. Introduction2. Patients and methods3. Results4. DiscussionReferences |
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Mitral as well as tricuspid valve repair feasibility has been well demonstrated in young rheumatic patients [1]. The most common mitral dysfunction in rheumatic patients is posterior leaflet restricted motion which can be corrected using the standard Carpentier technique of repair (secondary chord resection for posterior leaflet mobilization or pericardial patch extension of the posterior leaflet). Pericardial patch enlargement [2,3] is attractive in the case of severe retraction of the posterior leaflet, allowing effective leaflet enlargement and one to two higher size prosthetic ring insertions. We reserved anterior pericardial patch enlargement to retraction of the anterior leaflet encountered in particularly severe rheumatic mitral valve disease. Except in case of associated endocarditis damage, prolapse is not the predominant dysfunction encountered in rheumatic disease. The most usual lesion encountered is an increased space between the paramedian chords resulting in some degree of prolapse of median free edge anterior leaflet. This lesion can be corrected by anterior secondary chord transposition at the midpoint of the anterior leaflet free edge. The other lesions encountered are chord elongation or papillary muscle elongation, which can be corrected by chord shortening or papillary muscle sliding plasty.
The pericardial aortic cusp extension technique of repair has been developed by Duran et al. [4–6]. We have adopted a simplification of the initial technique which appears to be adapted to the most common lesions in rheumatic aortic valve insufficiency: cusp retraction resulting in central regurgitation that requires leaflet extension to increase the area of leaflet coaptation [4].
The long-term outcome of this triple valvular plasty is uncertain. The material of choice for extension is still debated [4–6,11]. Glutaraldehyde-stabilized autologous pericardium that we used has provided good initial and mid-term results. But patches could retract and in previously reported groups, the reintervention rate of aortic extension has been about 10% [6,12]. In fact in our group all valvular reoperations (rate of which was 10%) were due to progression of rheumatic disease, which is known to be the main cause of reoperation after surgical valvuloplasty in rheumatic patients, particularly in the young [13].
However, ideal surgical alternative techniques are not available because of the lack of ideal valve substitutes for the young and particularly in this setting of young rheumatic foreign patients that cannot have long-term anticoagulation [14,15]. Homografts still have antigenic properties and less durability when implanted in the young than in adult populations, as has already been reported [16,17]. The Ross procedure is a more technically demanding, more time-consuming procedure with concerns regarding the issue of the homograft pulmonary valve replacement [18,19], and limited benefits have been reported with the Ross procedure in young rheumatic patients [20]. We have not associated this procedure with double mitral and tricuspid valvuloplasty. We usually completed mitral valvuloplasty by aortic homograft implantation, when aortic repair was not accessible with the cusp extension technique because of pericardial adhesion, cusp prolapse, calcification or excessive thickness. On the other hand, when mitral repair was unfeasible, which is particularly rare in this setting of young patients, double valve replacement was necessarily required. Because of deceptive results we encountered with the mitral homograft in the young we now do not use this technique [21] in this situation.
Of course, the problem is different with patients originating from the Western world in which long-term anticoagulation is available. However, triple valvuloplasty could be interesting as a palliative procedure while awaiting native annulus growth, especially in the aortic annulus in children, or awaiting a less critical period for definitive anticoagulation.
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Footnotes |
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References |
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TopAbstract1. Introduction2. Patients and methods3. Results4. DiscussionReferences |
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This article has been cited by other articles:
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  T. Kazui, H. Kin, H. Izumoto, T. Nakajima, K. Ishihara, and K. Kawazoe Combined Aortic and Mitral Valve Repair Asian Cardiovasc Thorac Ann, December 1, 2003; 11(4): 319 - 322. [Abstract] [Full Text] [PDF]
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