Eur J Cardiothorac Surg 2002;22:630-632
© 2002 Elsevier Science NL
Mitral valve replacement with bileaflet preservation: a modified technique
Erkan Kuralay*,
Ufuk Demirkiliç,
Celalettin Günay,
Harun Tatar
Gülhane Military Medical Academy, Cardiovascular Surgery Department, Etl
k, Ankara 06010, Turkey
Received 22 January 2002;
received in revised form 9 July 2002;
accepted 19 July 2002.
* Corresponding author. Tel.: +90-312-326-3855; fax: +90-312-232-3038
e-mail: ekural{at}gata.edu.tr
e-mail: erkanece2000{at}yahoo.com
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Abstract
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We present a modified bileaflet preserving mitral valve replacement technique to eliminate left ventricular outflow tract obstruction and larger size prosthesis implantation. Mitral anterior leaflet was incised from the middle of leaflet to mitral annulus. Pletgetted sutures were firstly bitten from mitral annulus and then passed from the bottom to the tip of anterior leaflet. These sutures were anchored to prosthesis. Bileaflet prosthesis was put down into the annulus and sutures were ligated on the strut of prosthesis. Posterior leaflet was also preserved. Excessive anterior leaflet tissue was attached to left atrium wall by deeply bitten sutures.
Key Words: Left ventricle outflow tract obstruction • Bileaflet preservation • Mitral valve replacement
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1. Introduction
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Satisfactory results of bileaflet preserved mitral valve replacement (MVR) had been presented in several institutions with various modifications [1,2]. These modifications of preserving subvalvular apparatus were required to prevent the preserved tissue from interfering with prosthetic valve function, to implant an adequate size of valve and to prevent left ventricle outflow tract (LVOT) obstruction. LVOT obstruction is the main complication of bileaflet preserving operation that has been reported during recent years [3,4]. We present a modified technique to eliminate LVOT obstruction risk with bileaflet preservation
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2. Surgical technique
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Modified bileaflet preserving MVR was done via left atrial approach. Left atrium was opened along Sondergaard's groove then mitral valve was inspected. Fused commissures were incised towards mitral annulus. Fused and slightly thickened chordae were mobilized. Mitral anterior leaflet was incised from the middle of leaflet, which is devoid of chordal insertion, to mitral annulus without chordae injury. Stay sutures were located on each parts of anterior leaflet to facilitate next suturing. Pletgetted 2-0 Ti-Cron sutures were firstly bitten from mitral annulus then second bite was passed from the bottom to the tip of anterior leaflet (Fig. 1)
. These sutures were then anchored to bileaflet mitral prosthesis. Posterior leaflet was also preserved by leaflet plicating sutures. Bileaflet prosthesis was put down into the annulus and sutures were ligated on the strut of prosthesis. Excessive anterior leaflet tissue was attached to left atrium wall by deeply bitten sutures (Fig. 2)
. Prosthesis was placed perpendicularly to original mitral valve orifice. Transesophageal echocardiographic (TEE) examinations were done both in preoperative and postoperative periods. St. Jude prosthesis was used in all patients. Twenty-seven sized prosthesis was used in 35 patients.
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Fig. 1. Each commissure of mitral valve is freed and mitral anterior leaflet is incised from the middle segment, which is devoid of chordal insertion. Stay sutures were attached to two parts of mitral anterior leaflets to facilitate next suturing. Pledged 2/0 Ti-Cron suture was firstly bitten from mitral annulus and secondly from the bottom to the tip of anterior leaflet. Mitral posterior leaflet was also preserved by plicating sutures.
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Fig. 2. Sutures were attached to St. Jude prosthesis. St. Jude prosthesis was put down into the mitral annulus and the sutures were tied on the prosthesis strut. Retained mitral anterior leaflet tissues were attached to left atrial wall by deeply bitten sutures.
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A modified bileaflet preserved MVR was performed in 43 patients with degenerative mitral valve insufficiency between February 1997 and January 2000. All patients were informed about the technique and informed consent was obtained. Neither operative nor hospital mortality were developed. Cross-clamp period was slightly longer in bileaflet preserved MVR than conventional MVR operations. Inotropy was required in seven patients to wean from cardiopulmonary bypass. Resting ejection fraction (EF, %) increased from preoperative 52.7±3.8 to postoperative 62.8±3.1. Exercise EF (%) increased from preoperative 53.1±3.1 to postoperative 64.1±2.4. TEE examination was routinely done during the operations. Both leaflets of the prosthesis were freely mobile without any limitation in all patients. There was not LVOT obstruction and prosthesis related complication in both groups. Trans-thoracic echocardiographic examination was also done in the postoperative period. LVOT obstruction was not found in any patients. Thirty-one patients were remained in Class I and 12 were remained in Class II according to New York Heart Association classification. No bleeding and thrombosis/embolic complication was found during the follow-up period.
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3. Discussion
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MVR with preservation of both anterior and posterior leaflets and all chordae tendinea was introduced by David and colleagues who showed that improved left ventricle performance and the postoperative ejection fraction increased both during rest and exercise after operation [5]. Satisfactory results of bileaflet preservation forced several institutions and they begun to preserve both leaflets during the MVR so several modifications have been presented [1,2,6–8]. The principle of the preservation of subvalvular apparatus is to prevent LVOT obstruction, to prevent the preserved tissue from interfering with prosthetic valve function and to implant an adequate size of valve for the patient [1–8]. LVOT obstruction is the main complication of bileaflet preserving MVR that has been reported during recent years. The redundant chordae tendinea, the reduction of left ventricular size after surgery and especially systolic anterior motion of the native anterior mitral leaflet occurs commonly after prosthetic mitral valve insertion, while the native intact valve might cause LVOT obstruction [3,4]. Several modifications were presented to eliminate LVOT obstruction after bileaflet preserving MVR operations. H.L. Feike [1], and Z.-K. Wu [6] have incised entire anterior leaflet from annulus and reaffixed close to posterior leaflet and posterior wall. The function of papillary muscle may be preserved but anterior regional wall motion may not always improve in these techniques because the movement of posterior wall may be strengthened excessively by the preserved chordae tendineae [7]. The preservation techniques using the in situ position of the anterior leaflet and chordae may maintain an adequate global and regional cardiac function after MVR [7]. Modified bileaflet preserving technique, which we have been using in our department allowed in situ position of the preserved anterior leaflet. Excessive anterior leaflet remained in left atrial side instead of left ventricle, which completely eliminates risk of LVOT obstruction. T.J. Vander Salm et al. [8] described a technique by completely plicating anterior leaflet of mitral valve. I think that technique may impede larger size prosthesis insertion and cannot be applied to thickened valves.
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References
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- Feikes H.L., Daugharthy J.B., Perry J.E., Bell J.H., Hieb R.E., Johnson G.H. Preservation of all chordae tendinea and papillary muscle during mitral valve replacement with tilting disk valve. J Card Surg 1990;5:81-88.[Medline]
- Sintek C.F., Pfeffer T.A., Kochamba G.S., Khonsari S. Mitral valve replacement: technique to preserve the subvalvular apparatus. Ann Thorac Surg 1995;59:1027-1029.[Abstract/Free Full Text]
- Come P.C., Riley M.F., Weintraub R.M., Wei J.Y., Markis J.E., Lorell B.H., Grossman W. Dynamic left ventricular obstruction when the anterior leaflet is retained at prosthetic mitral valve replacement. Ann Thorac Surg 1987;43:561-563.[Abstract]
- Waggoner Ad., Perez J.E., Barzilai B., Rosenbloom M., Eaton M.H., Cox J.L. Left ventricular outflow obstruction resulting from insertion of mitral prostheses leaving the native leaflets intact: adverse clinical outcome in seven patients. Am Heart J 1991;122:483-488.[Medline]
- David T.E., Burns R.J., Bacchus C.M., Druck M.N., Weisel R.D. Mitral valve replacement for mitral regurgitation with and without preservation of chordae tendineae. J Thorac Cardiovasc Surg 1984;88:718-725.[Abstract]
- Wu Z.K., Sun P.W., Zhang X., Zhong F.T., Tong C.W., Lu K. Superiority of mitral valve replacement with preservation of subvalvular structure to conventional replacement in severe rheumatic mitral valve disease: a modified technique and results of 1 year follow-up. J Heart Valve Dis 2000;9:616-622.[Medline]
- Natsuaki M., Itoh T., Tomita S., Furukawa K., Yoshiaki M., Suda H., Ohteki H. Importance of preserving the mitral subvalvular apparatus in mitral valve replacement. Ann Thorac Surg 1996;61:585-590.[Abstract/Free Full Text]
- Vander Salm T.J., Linda A.P., Mauser J.F. Mitral valve replacement with complete retention of native leaflets. Ann Thorac Surg 1995;59:52-55.[Abstract/Free Full Text]
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Abstract
1. Introduction
