Eur J Cardiothorac Surg 2006;29:1052-1055
© 2006 Elsevier Science NL
The upside-down technique.
A novel method to correct posterior leaflet prolapse
Francesco Maisano
*
,
Ottavio Alfieri
Cardiac Surgery Unit, San Raffaele University Hospital, 20132 Milan, Italy
Received 17 January 2006;
received in revised form 2 March 2006;
accepted 10 March 2006.
* Corresponding author. Tel.: +39 02 26437111; fax: +39 02 26437125. (Email: francesco.maisano{at}hsr.it).
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Abstract
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The upside-down technique is a method for ‘in situ’ secondary cordae transposition for posterior leaflet lesions. The segmental prolapse of the posterior leaflet is corrected by rotating the resected segment upside-down and reattaching it to the annulus and adjacent leaflet segments. As the procedure is completed, the original annular attachment becomes the new free edge. The secondary chords, originally positioned at the base of the segment, become primary chordae. It is indicated in all cases when quadrangular resection is not feasible such as in case of calcified annulus, posterior leaflet hypoplasia, or when the prolapsing portion is wide.
Key Words: Mitral valve repair • Secondary chordae • Prolapse
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1. Background
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Posterior leaflet type II lesions [1] involving the mid scallop (P2) are, usually, simple to repair. The most used technique is quadrangular resection, with or without sliding plasty. However, in case of calcified annulus, posterior leaflet hypoplasia, or when the prolapsing portion is wide (Fig. 1a and b), quadrangular resection may not be feasible. In such occasions, alternative techniques have been proposed, including chordal replacement, secondary chordae transfer and edge-to-edge technique [2,3].
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Fig. 1. Scheme of the surgical procedure: (a) sketch of the mitral valve as seen by the surgeon. There is a wide area intersected by the prolapse, incorporating all P2 region; (b) primary chordae rupture is present, and the prolapsing segment is flail and redundant; (c) the diseased segment is resected, leaving all chordae in situ. The line of resection is indicated by dotted lines; (d) all primary chordae and secondary chordae attached to the rough zone are resected. Excessive tissue on the free edge is resected at this time to avoid subsequent redundancy. The position of the cut at the base of the segment, between the annulus and the chordae connected to the base of the leaflet, is indicated by dotted lines; (e) the segment with the secondary chordae in situ is rotated; (d) the rotation is obtained by pulling on the free edge and by pushing the base of the leaflet into the ventricle; (g) the segment is reattached to the annulus and to the adjacent scallops with continuous and/or interrupted sutures; and (h) the secondary chordae, originally attached at the base of the leaflet, are now acting as primary chordae.
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We describe an alternative solution, which we called the upside-down (UpDwn) technique, as a method for ‘in situ’ secondary cordae transposition to be used in similar occasions (Figs. 1 and 2
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Fig. 2. Intraoperative views: (a) a secondary chorda attached at the base of the prolapsing leaflet is identified by the nerve hook before resection; (b) following completion of the resection of the prolapsing segment, the secondary chordae attached at the base of it are easily identifiable (asterisks); (c) primary chordae (asterisk) are severed from the tip of the papillary muscle and resected to avoid subsequent restriction; (d) the rotated segment has been reattached to the annulus and is going to be attached to the adjacent P1 with interrupted stitches; (e) following completion of the procedure, a secondary chorda is pulled to show its new position. Note the fan-shaped attachment of it to the leaflet (asterisk); and (f) water-testing shows perfect competence of the valve, the height of coaptation is the same for both leaflets and the rotated segment is not distinguishable from the rest of the posterior leaflet, besides the presence of some stumps of the severed chordae (asterisk), that are going to be removed to make the coaptating surface as smooth as possible.
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2. Surgical technique
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Mitral valve inspection is carried out as usual. All available healthy secondary chordae attached at the base of the diseased segment are identified (Fig. 2a). Leaflet detachment is performed as usual, starting with two ‘vertical’ incisions, perpendicular to the annulus, from the free edge to the annulus. An additional resection is made at the base of the leaflet, between the annulus and the attachment of the secondary chordae (Figs. 1c, d and 2b), which are left on the leaflet. Once the segment has been resected, before it can be rotated, all primary chordae are severed from the free margin (Figs. 1d and 2c). Only chordae attached to the base of the leaflet should be left in place, while those attached to the rough zone should be cut, in order to avoid restricted motion once the leaflet is rotated (Fig. 1d). Any excessive tissue is resected at this time to avoid redundancy at the end of the procedure (Fig. 1d). The segment is rotated by pulling the original free edges towards the atrium and pushing the original annular margin towards the ventricle (Fig. 1e and f). The segment is reattached to the rest of the posterior leaflet using 5-0 polypropylene sutures (Fig. 1g and h). The annular portion (originally the free edge) is sutured first. Unless any additional resection is made, the lengths of the rotated segment and of the annulus exactly match. Once the annular portion has been reattached, the segment can be reconnected to the adjacent P1 and P2 segments by interrupted (preferred) or continuous sutures (Fig. 2d). At this time, the ex-ventricular surface of the leaflet is exposed, and it is easy to cut any secondary chorda not attached to neo free edge of the leaflet, and exerting any restriction in the motion of the leaflet itself. Care should be taken in ‘cleaning’ the surface of the leaflet, following rotation, by cutting all the stumps of the cut chordae, to avoid central jets related to inefficient coaptation (observed in one case in our series).
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3. Clinical experience
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Since January 2004, six patients with P2 prolapse were treated by the UpDwn technique. The diseased segment involved more than 50% of the posterior leaflet. Additionally, in four patients, the adjacent segments (P1 and P3) were hypoplastic. Partial posterior flexible band annuloplasty was associated in all patients to reinforce the repair and to stabilize the result. Repair was acutely successful in all patients, and at latest follow-up (mean 10 ± 4 months, range 4–18 months) transthoracic echocardiography shows stable results, with one patient showing mild (2/4) central, non-eccentric residual MR (already observed early intraoperatively), in absence of motion abnormalities of the rotated leaflet, while all other patients had no or trace MR.
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4. Discussion
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Secondary cordae attached to the base of the leaflet have, usually, normal length since the distance between the tip of the papillary muscle to the annulus defines the ‘normal length’ of chordae. Their implantation on the free edge of a prolapsing leaflet restores normal coaptation. With the UpDwn technique, these secondary chordae are transferred to the free margin of the posterior leaflet, by rotation of the diseased segment, without the need for reimplantation and maintaining the natural, fan-shaped attachment to the leaflet. The preservation of the natural attachments of the chordae to the leaflet enables better stress distribution to the leaflet and avoids the risk of shortening the chordae related to the suture used for the reimplantation. In comparison to neo-chordae implantation, the UpDwn technique avoids the issue of sizing the neo-chordal length.
Another advantage of the technique is that at the end of the procedure, differently from what observed in quadrangular resection, all papillary muscle tips are still connected to the mitral valve by native chordae, suggesting a better preservation of the mitral-ventricular integrity [4].
The UpDwn technique should not be adopted in case of diseased secondary chordae or when the leaflet tissue is calcified or otherwise diseased. Although the role for this new technique has to be determined, it could be helpful in patients with extended prolapse of the posterior leaflet, and in all cases when complete preservation of subvalvar apparatus is deemed necessary.
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Footnotes
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Presented at the joint 19th Annual Meeting of the European Association for Cardio-thoracic Surgery and the 13th Annual Meeting of the European Society of Thoracic Surgeons, Barcelona, Spain, September 25–28, 2005.
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References
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- Carpentier A. Cardiac valve surgery-the "French correction". J Thorac Cardiovasc Surg 1983;86:323-337.[Medline]
- Zussa C, Polesel E, Da Col U, Galloni M, Valfre C. Seven-year experience with chordal replacement with expanded polytetrafluoroethylene in floppy mitral valve. J Thorac Cardiovasc Surg 1994;108:37-41.[Abstract/Free Full Text]
- Maisano F, Torracca L, Oppizzi M, Stefano PL, D’Addario G, La Canna G, Zogno M, Alfieri O. The edge-to-edge technique: a simplified method to correct mitral insufficiency. Eur J Cardiothorac Surg 1998;13:240-245.[Abstract/Free Full Text]
- Yun KL, Sintek CF, Miller DC, Pfeffer TA, Kochamba GS, Khonsari S, Zile MR. Randomized trial comparing partial versus complete chordal-sparing mitral valve replacement: effects on left ventricular volume and function. J Thorac Cardiovasc Surg 2002;123:707-714.[Abstract/Free Full Text]
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Abstract
1. Background
