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a Assistance Publique – Hôpitaux de Paris, AP-HP; Service de Chirurgie Cardiovasculaire, Hôpital Européen Georges Pompidou, Paris, France
b Université René Descartes, Paris V, France
Received 24 September 2007; received in revised form 27 May 2008; accepted 29 May 2008.
* Corresponding author. Address: Hôpital Européen Georges Pompidou, Service de Chirurgie Cardiovasculaire, 20, rue Leblanc, 75908 Paris, France. Tel.: +33 1 56 09 37 48; fax: +33 1 56 09 22 19. (Email: rzegdi{at}hotmail.com).
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Abstract |
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 Top Abstract 1. Introduction2. Materials and methods3. Results4. DiscussionReferences |
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3+ mitral regurgitation. Repair was mainly performed using Carpentier's techniques. Results: Repair failure was due to posterior leaflet prolapse, leaflet retraction or leaflet dehiscence in eight (62%), three (23%) and two (15%) patients, respectively. Repair was performed in nine patients (69%). There was no perioperative death. During follow-up (median: 105 months; range: 40–170 months) one late death occurred in the mitral valve replacement group. One (11%) patient underwent mechanical mitral valve replacement 125 months after re-repair. Congestive heart failure occurred in one patient in each group. At the latest follow-up, all but one patient in the mitral valve repair group were in NYHA functional class I or II and all were in sinus rhythm. Doppler echocardiographic studies of the re-repaired valves (n
= 8) showed no or trivial, grade 1+ and grade 2+ residual mitral regurgitation in 6 (75%), 1 and 1 patients, respectively. Mean transmitral gradient was 3 mmHg (2–8 mmHg) and left ventricular ejection fraction was 59% (43–77%). Conclusion: In case of late posterior failure of mitral valve repair for severe degenerative, re-repair is feasible in about 70% of the patients with encouraging results at 10 years.
Key Words: Heart valve • Mitral valve repair • Surgery
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1. Introduction |
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TopAbstract1. Introduction2. Materials and methods3. Results4. DiscussionReferences |
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Few surgical series dealing with reoperation for failure of MVRep have been published [7–9]. In a recent surgical series, re-repair was performed in almost 50% of patients and was found to be an independent predictor of long-term survival [8].
Repair failure may be caused by lesions affecting exclusively the mitral posterior leaflet. Little is known regarding the mechanisms, the feasibility and the early and long-term results of re-repair in these cases of ‘posterior failure’ of a previous MVRep.
We report in this paper our 16-year experience in reoperation in this clinical setting.
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2. Materials and methods |
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TopAbstract1. Introduction2. Materials and methods3. Results4. DiscussionReferences |
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Etiology of the primary valve disease was Barlow's disease and fibroelastic deficiency in five (38%) and eight patients (62%), respectively. Indication for first surgery was severe MR due to posterior prolapse in eight patients (62%) and bileaflet prolapse in five (38%). Commissural prolapse was present in two patients (15%). Surgical details regarding the first operation are listed in Table 1 . Pre-discharge transthoracic echocardiography (TTE) revealed no or grade 1+ residual mitral regurgitation in 12 (92%) patients and grade 2+ regurgitation in 1 (8%) patient.
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Median time interval between first and second operation was 48 months (2–120 months). Reoperation was indicated for recurrent severe mitral regurgitation (grade 3+) in all patients.
2.2 Valve analysis and surgery
All the operations were performed through a median sternotomy on full cardiopulmonary bypass between the two vena cavae and the ascending aorta. Mild systemic hypothermia (28–30 °C) was used in all cases. Myocardial protection was identical for all patients and consisted of an antegrade cold blood crystalloid cardioplegia. Mitral valve exposure was achieved through a standard left atriotomy along the interatrial groove.
During surgery, valve inspection revealed a posterior prolapse in eight (62%) due to chordal rupture or elongation. Posterior leaflet restricted motion was found in three patients (23%) and leaflet dehiscence in two (15%). Prosthetic ring dehiscence was also noticed in one patient (8%).
The decision to perform re-repair was left to the surgeon depending on the lesions, his experience and the patient's wish. Each mitral valve repair was assessed intraoperatively by transesophageal echocardiography and at discharge by transthoracic echocardiography.
2.3 Follow-up
Long-term follow-up data were obtained through questionnaires and telephone contacts with patients or relatives, physicians and cardiologists. Long-term results were assessed on the basis of NYHA functional class, electrocardiogram and echocardiography. Cardiac rhythm, thromboembolic or bleeding events, endocarditis and reoperations were systematically recorded.
2.4 Statistics
Data were expressed as median (range) for continuous variables and as percentage for categorical variables. Cumulative survival and freedom from events were obtained using the Kaplan–Meier method.
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3. Results |
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TopAbstract1. Introduction2. Materials and methods3. Results4. DiscussionReferences |
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Time interval before reoperation was 27 months (2–120 months) for patients with procedure-related factors and 47 months (21–92 months) for patients with valve-related factors.
3.2 Feasibility of redo MVRep
During the 16-year study, 13 consecutive patients with degenerative mitral valve disease were admitted to our department for late posterior failure of MVRep. Among them, nine patients (69%) underwent a second MVRep and the four others a mitral valve replacement (MVR) with either bioprosthesis (n
= 2), mechanical prosthesis (n
= 1) or mitral homograft (n
= 1). When performed, valve reconstruction was mainly performed according to Carpentier's techniques [10]. The re-repair techniques are reported in Table 1.
3.3 Operative mortality and morbidity
There was no perioperative death in this series. Major postoperative morbidity mainly included low cardiac output syndrome and bleeding in five (42%) and one patient (8%). Median intensive care unit stay and hospital stay were 2 days (1–9 days) and 12 days (7–25 days), respectively.
In the MVRep group, transthoracic echocardiography at discharge showed no or trivial residual MR in eight patients (89%) and grade 1+ in one (11%). There was no perivalvular leak in the MVR group.
3.4 Long-term outcomes
Follow-up was complete in all patients. Median follow-up was 105 months (40–170 months). There was no late death in the MVRep group whereas one (25%) patient from the MVR group died from congestive heart failure 160 months after his reoperation.
There was no reoperation in the MVR group. Ten-year freedom from reoperation was 100% in the MVRep group. However, one (11%) patient was reoperated 125 months after re-repair. After initial quadrangular resection for posterior leaflet prolapse, re-repair was performed 7 months later for suture dehiscence. Posterior leaflet continuity was re-established by interposition of an autologous pericardial patch. Stabilization of this patch was achieved by chordal transfer. Late failure of this re-repair was due to rupture of the transferred chordae. This patient underwent mechanical MVR at third operation.
One (11%) patient in the MVRep group suffered from a transient ischemic attack. Congestive heart failure occurred in one patient in both groups. No case of endocarditis was recorded.
At last follow-up, one patient in each group was in NYHA functional class III whereas all the others were in NYHA functional class I or II. All patients in the MVRep group were in sinus rhythm. Atrial fibrillation was present in one patient of the MVR group. Doppler echocardiographic studies of the re-repaired valves (n = 8) showed no or trivial, grade 1+ and grade 2+ residual MR in six (75%), one and one patients, respectively. Mean transmitral gradient was 3 mmHg (2–8 mmHg) and left ventricular ejection fraction was 59% (43–77%).
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4. Discussion |
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TopAbstract1. Introduction2. Materials and methods3. Results4. DiscussionReferences |
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The causes of failed MVRep have been classified into two categories. Procedure-related factors with a 35–58% relative frequency include incomplete initial repair, suture or prosthetic ring dehiscence and rupture of previously shortened chordae [5–7]. Valve-related factors include progression of the degenerative process or endocarditis. In our series, repair at first operation involved the posterior leaflet in all patients. Three types of lesions of the posterior leaflet were encountered and judged as responsible for the recurrence of MR. These lesions included a decreasing incidence leaflet prolapse (62%), retraction (23%) or dehiscence (15%).
The feasibility of MVRep after failure of a previous one has been reported to vary between 10% and 44% in degenerative disease [7,8,10,11]. During the same time period, 43 patients with repair failure were reoperated on in our department. Among the 13 patients with posterior repair failure, re-repair was performed in 69% of cases. Re-repair was done in only 12 (40%) of the 30 patients with ‘anterior repair failure’, either isolated or not.
The feasibility of MVRep depends on two factors (the golden rules): that is, the availability of a sufficient amount of leaflet tissue, which must be pliable (non fibrotic or non calcified). These two prerequisites are usually present in late failure of MVRep. Retrospectively, re-repair was technically possible in the three out of four patients who underwent MVR. Re-repair was not performed because the surgeons or the patients were reluctant to confront the hazards of a second valve repair.
In our experience, a satisfying exposure of the mitral valve was achieved through an atriotomy along the interatrial groove. Complete dissection of the heart was not necessary when access to the subvalvular apparatus was not required. From a purely technical aspect, the two main mechanisms of MR recurrence, valve prolapse and leaflet retraction, were easily corrected by either valvular resection, chordal transfer, use of artificial chordae or pericardial valvular extension [12].
Durability of re-repair is a critical issue. In the largest experience to date, freedom from reoperation was 83% at 5-year follow-up [8]. Long-term echocardiographic data of the repair were unavailable limiting the value of this study [13]. However, despite this limitation, MVRep was found to be an independent predictor of late survival. In the present study, 10-year freedom from reoperation was 100% and the reoperation rate was 11% with a median follow-up of 105 months. Our echocardiographic data revealed satisfying results of the re-repair in the non-reoperated patients (87% of no or grade 1+ residual MR).
The study has however two main limitations that must be accounted for. First of all, only 13 patients were included in the study. This limited number of patients despite a 16-year study period reflects mainly the excellent long-term durability of MVRep in degenerative disease. Moreover, in our experience, posterior failure only accounts for one third of all cases of late failure of MVRep. Finally, our results also reflect the current experience of a single center with a high level of expertise in mitral valve reconstruction.
In conclusion, redo MVRep was possible in nearly 70% of cases of late posterior failure of previous MVRep for severe degenerative MR. Redo MVRep was associated to a null operative mortality and satisfying long-term results (100% 10-year survival or freedom from reoperation rate).
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References |
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TopAbstract1. Introduction2. Materials and methods3. Results4. DiscussionReferences |
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