Atlas of Mitral Valve Repair, 1st Edition

11

Other Techniques

LEAFLET DEBRIDEMENT

Areas of the leaflets can be stiff and thickened commonly seen with rheumatic disease. Sharp excision of fibrous tissue and the removal of calcium can improve leaflet apposition and eliminate leaks between the leaflets.

CHORDAL LENGTHENING

For Type IIIA leaflet abnormalities papillary muscle and chordal lysis, primarily used for mitral stenosis, can be used to free the chordae, allowing increased valvular excursion (Fig. 11.1; See Fig. 7.2). This is particularly important when repairing regurgitation secondary to rheumatic disease in which chordal and papillary muscle shortening has pulled the leaflets down into the ventricle, preventing the normal doming of the leaflet and shortening the coaptation surface.

CHORDAL CUTTING RELEASE

Messas et al. described focused cutting of selected second-order chordae to the anterior leaflet to reduce regurgitation by eliminating deformation of the leaflet (or “seagull” deformity) in a sheep model of mitral regurgitation (Fig. 11.2) (1). This effect was sustained long term (2). This technique has been used clinically to release tethering of the posterior and anterior leaflets. Once bowing of the leaflet is released there is better apposition with the opposite leaflet.

 

Figure 11.1 Release of secondary chordae to improve leaflet mobility. (Clip 3, Case 3) 

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Figure 11.2 Chordal cutting to alter the shape of the leaflet. (From Messas E, Guerrero JL, Handschumacher MD, et al. Chordal cutting: a new therapeutic approach for ischemic mitral regurgitation. Circulation. 2001;104:1958-1963.)

POSTERIOR PAPILLARY MUSCLE RELOCATION

With chronic ischemic mitral regurgitation the posterior papillary muscle is displaced apically (3). Hung et al. documented, in an animal model, that simple repositioning of the bulging posterior wall and associated papillary muscle into the ventricle with associated reduction of apical traction of the mitral leaflets reversed mitral regurgitation (4). This reversal was demonstrated in a sheep model with posterior suture plication (Fig. 11.3) (5).

This principle was applied by Kron et al., who detailed a technique to promote repair in the presence of a Carpentier Type IIIb leaflet abnormality caused by tethering of the leaflets to the posterior papillary muscle with resultant traction into the ventricle (6). As the annulus may not be dilated, annuloplasty alone may not correct the regurgitation. They performed this repair by passing a 3-0 polypropylene suture twice through the fibrous portion of the posterior papillary muscle then through the annulus just posterior to the right fibrous trigone (Fig. 11.4). Once the annuloplasty ring was in place, tension on this relocating

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suture was adjusted to maximize leaflet coaptation. They reported excellent early results in 18 patients. However, given the significant stress placed on the papillary muscle, Carpentier expressed concern about the long-term durability of this approach (A. Carpentier, personal communication).

 

Figure 11.3 Posterior suture plication to reposition the papillary muscle. (From Liel-Cohen N, Guerrero JL, Otsuji Y, et al. Design of a new surgical approach for ventricular remodeling to relieve ischemic mitral regurgitation: insights from 3-dimensional echocardiography. Circulation. 2000;101:2756-2763.)

 

Figure 11.4 Posterior papillary muscle relocation for Type IIIb abnormality. (From Kron IL, Green R, Cope JT. Surgical relocation of the posterior papillary muscle in chronic ischemic mitral regurgitation. Ann Thorac Surg. 2002;74:600-601.)

 

Figure 11.5 Gore-Tex® tube encircling the trabecular base of the posterior and anterior papillary muscle, tightened and secured with sutures to bring the papillary muscles into close contact. (From Hvass U, Tapia M, Baron F, Pouzet B, Shafy A. Papillary muscle sling: a new functional approach to mitral repair in patients with ischemic left ventricular dysfunction and functional mitral regurgitation. Ann Thorac Surg. 2003;75:809-811.)

PAPILLARY MUSCLE SLING

An alternative technique for reducing posterior papillary muscle displacement was described by Hvass et al. (7). They created a papillary muscle sling using a 4-mm Gore-Tex® tube graft to pull the papillary muscles together to complement the support of an annuloplasty ring (Fig. 11.5). They demonstrated a reduction in the tenting effect from 14 ± 2.8 millimeters to 4 ± 1.41 millimeters.

CHORDAL SHORTENING

Chordal shortening procedures at the level of the papillary muscle are discussed here for historical significance, and to recommend against future application. This technique was described by Carpentier (8) and involved burying the elongated chord in a slit made in the papillary muscle as depicted in Figure 11.6. Smedira et al. reviewed their results and noted a 5-year actuarial freedom from reoperation of 96% after chordal transfer (discussed below) (posterior leaflet transfer [75%], transfer of a secondary chorda [21%], or both [3%] to the free edge of the anterior leaflet) and 74% after chordal shortening, p = 0.003, noting that chordal shortening was an independent predictor of reoperation (9). This was confirmed by El Khoury et al. (10) and Fucci et al. (11). The failure mode noted for this repair is depicted in Figure 11.7.

In response to this, Fundaro et al. updated the results of their chordal shortening technique with a technique described as “free edge remodeling” (12), (see Chapter 8, Figs. 8.4,8.5). Here they present a slight alteration in the technique for chordal shortening demonstrated in Fig. 11.8. They reported a 3.2% reoperation rate for recurrent prolapse at 16.8 months.

An alternative chordal shortening technique was described by Duran wherein the papillary muscle head is repositioned (13) (Figs. 11.9 and 11.10). Similar to this is the papillary

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muscle repositioning described by Dreyfus et al. as an alternative to chordal shortening with similar long-term results (Fig. 11.11) (14).

 

Figure 11.6 Technique of chordal shortening. (From Muehrcke DD, Cosgrove DM. Mitral valvuloplasty. In: Edmunds, Jr. LH, ed. Cardiac Surgery in the Adult. New York: McGraw-Hill, 1997:1006.)

 

Figure 11.7 Chordal shortening failure mode. (From Smedira NG, Selman R, Cosgrove DM, et al. Repair of anterior leaflet prolapse: chordal transfer is superior to chordal shortening. J Thorac Cardiovasc Surg. 1996;112:287-291.)

 

Figure 11.8 Technique of chordal suture plication and free edge remodeling, compare to Figures 8.4 and 8.5. (From Fundaro P, Lemma M, Di Mattia DG, Santoli C. Repair of anterior leaflet prolapse: chordal transfer versus chordal shortening. Which is better? J Thorac Cardiovasc Surg. 1997;114: 1125-1127.)

 

Figure 11.9 Chordal shortening by papillary muscle sliding plasty. (From Duran CMG. Surgical techniques for the repair of anterior mitral leaflet prolapse. J Card Surg. 1999:14;471-481.)

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PAPILLARY MUSCLE SHORTENING

Fasol et al. described a technique of papillary muscle shortening when the head became fibrotic and elongated causing prolapse and regurgitation (Fig. 11.12) (15). This technique was used to repair the valve in 88 patients with no failures on short-term follow-up.

 

Figure 11.10 Chordal shortening by papillary muscle head repositioning. (From Duran CMG. Surgical techniques for the repair of anterior mitral leaflet prolapse. J Card Surg. 1999:14;471-481.)

 

Figure 11.11 Posterior papillary muscle repositioning. (From Dreyfus GD, Bahrami T, Alayle N, et al. Repair of anterior leaflet prolapse by papillary muscle repositioning: a new surgical option. Ann Thorac Surg. 2001;71:1464-1470.)

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Figure 11.12 Papillary muscle shortening. A: Normal, B: Elongated and fibrotic, C: repair suture placed, D: repair suture tied. (From Fasol R, Wild T, Pfannmuller B, Stumpf J, Hacker R. Papillary muscle shortening for mitral valve reconstruction in patients with ischemic mitral insufficiency. Eur Heart J. 1998;19:1730-1744.)

CHORDAL TRANSPOSITION OR TRANSFER

Two types of chordal transposition have been described: Transposition of a primary posterior leaflet chorda to the edge of the anterior leaflet and transposition of an anterior leaflet secondary chorda to the leaflet edge.

Transposition of a primary posterior leaflet chordae (also referred to as the flip-over technique (16) was described by Carpentier (8). This involves quadrangular resection of a portion of the posterior leaflet and primary closure, with transposition to the underside of the flail segment of the anterior leaflet (Fig. 11.13). Utilizing this technique in 39 patients,

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Lessana et al. reported a 97.4 ± 5.2% freedom from reoperation rate at 4 years (17). Similar results were reported by Salati et al.: 91.5 ± 5.2% in 48 patients at 3 years (18,19), Sousa Uva et al. (20), and Smedira et al. (9).

 

Figure 11.13 Posterior chordal transfer. (From Muehrcke DD, Cosgrove DM. Mitral valvuloplasty. In: Edmunds, Jr. LH, ed. Cardiac Surgery in the Adult. New York: McGraw-Hill. 1997:1007.)

 

Figure 11.14 Fixation of leaflet edge to secondary chorda. (From Carpentier A. Cardiac valve surgery—the “French Correction.” J Thorac Cardiovasc Surg. 1983;86: 323-337.)

Use of a secondary chorda to secure the leaflet edge was described by Carpentier who fixed the leaflet edge to the secondary chorda as demonstrated in Figure 11.14 (8). The transposition variant of this is shown in Figure 11.15.

A note of caution is raised by Nielsen et al. who reported that in a sheep model, isolated division of an anterior leaflet secondary chordae resulted in regional left ventricular systolic dysfunction near the insertion site (21). The clinical implications of this observation for mitral repair are unclear.

CHORDAL REPLACEMENT

Chordal replacement to correct anterior leaflet prolapse has been described as an alternative to shortening or transposition. Gregory et al. described a technique used in two patients in which

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a strip of leaflet from the anterior leaflet was sewn to the papillary muscle (Fig. 11.16) (22). Though an interesting technique, no long-term follow-up or reports of its utilization in additional patients could be found. Given the availability of other techniques with documented success application of this technique cannot be recommended.

 

Figure 11.15 Transposition of secondary chord to leaflet edge. (From Smedira NG, Selman R, Cosgrove DM, et al. Repair of anterior leaflet prolapse: chordal transfer is superior to chordal shortening. J Thorac Cardiovasc Surg. 1996;112:287-291.)

The use of various prosthetic materials has been reported to replace the damaged or diseased chordae, including expanded polytetrafluoroethylene (PTFE) (23,24) and glutaraldehyde-tanned xenograft pericardium (24), both demonstrating excellent long-term durability. The PTFE becomes covered with a normal fibrosa and intima and retains flexibility (25). Eishi et al. found pericardium to be inferior to PTFE and recommended against its use (26).

A number of techniques for the insertion of PTFE chordae have been published (13) (Figs. 11.17,11.18,11.19,11.20). The suture should be tied so the body of the leaflet is at the level of the annular plane (27) (Figs. 11.21,11.22,11.23,11.24).

David reviewed his experience in 1998: Of 324 repairs performed, he utilized PTFE chordae in 165 (Figs. 11.25,11.26,11.27). He noted no negative effect on long-term outcome with their use and felt that he was able to expand the number of valves repaired utilizing these techniques (28). Zussa et al. have confirmed these results (29,30). Chordal replacement has demonstrated superior long-term results in comparison to chordal shortening (31).

Technical Details

Most authors recommend 4-0 or 5-0 PTFE suture, though one recently espoused the use of 2-0, claiming that 5-0 was too weak. Determining the proper length for artificial chordae can be challenging. As Frater points out, successful achievement of ideal length for the new chordae is influenced by accurate determination of the length (the ideal length may differ from that determined in the flaccid heart) and accurately tying the knot (PTFE is slippery) (32).

A number of techniques have been described to determine appropriate length, including using tourniquets to adjust the length after the other aspects of the repair are complete (Fig. 11.28) (33). Adams et al. advocate using a surgeon's knot with saline testing to adjust the leaflet height instead of tourniquets and pledgets (Fig. 11.29), again, after the rest of the repair is completed (34). Sarsam advocates a different technique that can be applied with multiple areas of unileaflet and bileaflet prolapse. A temporary figure-of-eight suture is used to reapproximate the leaflet edges then the chordal suture, which was brought up

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through the rough portion of the valve, is tied with three knots to secure it, then looped again through the leaflet to secure it in place (Fig. 11.30) (35). In the case of bileaflet prolapse, the first suture is tied to approximate the plane of the mitral annulus then used as a reference for tying the remaining artificial chordal sutures. In contrast, Rankin recommends using a removable hemoclip to secure the suture during testing, then tying on the clips when the correct height is determined (36). Reimink et al., using a finite element model demonstrated that the ideal length of artificial chordae should be the same as or longer than the replaced chordae to optimize function and stress in the repaired valve (37).

 

Figure 11.16 Anterior leaflet strip to treat prolapse. (From Gregory F Jr, Takeda R, Silva S, Facanha L, Meier MA. A new technique for repair of mitral insufficiency caused by ruptured chordae of the anterior leaflet. J Thorac Cardiovasc Surg. 1988;96:765-768.)

 

Figure 11.17 Technique for insertion of Gore-Tex® chord using glutaraldehyde fixed pericardial pledgets. This approach has the disadvantage that the tied suture may impinge on the area of leaflet apposition. (From Zussa C. Different applications of ePTFE valve chordae: surgical technique. J Heart Valve Dis. 1996 Jul;5(4):356-361.)

 

Figure 11.18 Technique for placement of a single Gore-Tex®chord. A double loop around the leaflet edge rolls it under and prevents slippage while tying. (From Duran CMG. Surgical techniques for the repair of anterior mitral leaflet prolapse. J Card Surg 1999;14:471-481.)

 

Figure 11.19 Technique for placement of a multiple Gore-Tex®chords. (From Duran CMG. Surgical techniques for the repair of anterior mitral leaflet prolapse. J Card Surg.1999;14:471-481.)

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Figure 11.20 Alternative method of suturing to the leaflet edge below the plane of the valve coaptation. (From Phillips MR, Daly RC, Schaff HV, et al. Repair of anterior leaflet mitral valve prolapse: chordal replacement versus chordal shortening. Ann Thorac Surg. 2000;69:25-29.)

 

Figure 11.21 Anchoring the PTFE suture in the papillary muscle. (Clip 3, Case 4) 

 

Figure 11.22 Anchoring the PTFE suture in the anterior papillary muscle. (Clip 3, Case 6) 

 

Figure 11.23 Attachment of the PTFE suture to the anterior leaflet. (Clip 6, Case 6) 

 

Figure 11.24 Attachment of the PTFE suture to the anterior leaflet. (Clip 8, Case 4) 

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Figure 11.25 Technique for chordal replacement with Gore-Tex® suture. The double-armed suture is passed twice through the head of the papillary muscle and tied. The suture is then brought up to the free margin and passed through the point of the attachment of the original chorda. The suture is brought from the ventricular to the atrial side of the leaflet and passed through it again, rolling in the leaflet edge. The height is adjusted, the suture is passed through a third time, and its tied on the ventricular side. (From David TE, Bos J, Rakowski H. Mitral valve repair by replacement of chordae tendineae with polytetrafluoroethylene sutures. J Thorac Cardiovasc Surg. 1991;101:495-501.)

 

Figure 11.26 Technique for chordal replacement with Gore-Tex® suture. Similar to the technique in Figure 11.25 but for a wider segment of prolapse or to replace two adjacent chordae. Each segment of the suture is passed through the anchor point and run toward the other, avoiding crimping of the leaflet. (From David TE, Bos J, Rakowski H. Mitral valve repair by replacement of chordae tendineae with polytetrafluoroethylene sutures. J Thorac Cardiovasc Surg. 1991;101: 495-501.)

 

Figure 11.27 Alternative technique for chordae replacement with PTFE. (From David TE, Omran A, Armstrong S, Sun Z, Ivanov J. Long-term results of mitral valve repair for myxomatous disease with and without chordal replacement with expanded polytetrafluoroethylene sutures. J Thorac Cardiovasc Surg. 1998;115:1279-1285.)

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Figure 11.28 Technique for determining ideal length of artificial chordae. (From Kasegawa H, Kamata S, Hirata S, et al. Simple method for determining proper length of artificial chordae in mitral valve repair. Ann Thorac Surg. 1994;57: 237-238.)

 

Figure 11.29 Technique for optimizing length of the artificial chordae using a surgeon's knot to avoid slippage. (From Adams DH, Kadner A, Chen RH. Artificial mitral valve chordae replacement made simple. Ann Thorac Surg. 2001; 71:1377-1388.)

Techniques to prevent slippage while tying the suture include grasping the suture with a clamp or hemoclip at the cusp edge level (33) or passing the suture through the free edge several times to create friction and prevent slippage (32) (Figs. 11.31 and 11.32). If a clip is used, the suture can be tied against a clip and then the clip can be removed.

PTFE Chordal Replacement for Isolated Posterior Leaflet Prolapse

The use of PTFE to repair posterior leaflet prolapse as an alternative to excision of the P2 scallop has been described (38). Rather than excising the flail leaflet it is reattached to the papillary muscle. This may be easier than and just as effective as more complicated approaches (Fig. 11.33). Sutures may be necessary to secure the posterior leaflet and prevent prolapse after a sliding or folding plasty (Fig. 11.34).

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Figure 11.30 Technique to optimize length of artificial choral sutures. (From Sarsam MA. Simplified technique for determining the length of artificial chordae in mitral valve repair. Ann Thorac Surg. 2002;73:1659-1660.)

 

Figure 11.31 Chordal replacement with 4-0 PTFE suture. (From Chitwood Jr. WR. Mitral valve repair: ischemic. In: Kaiser LR, Kron IL, Spray TL. Mastery of Cardiothoracic Surgery. Philadelphia: Lippincott-Raven. 1998:320.)

 

Figure 11.32 Use of 5-0 PTFE to create artificial chordae. (From Kobayashi J, Sasako Y, Bando K. Ten-year experience of chordal replacement with expanded polytetrafluoroethylene in mitral valve repair. Circulation. 2000;102:III-30.)

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Figure 11.33 Repair of posterior leaflet prolapse with a PTFE replacement chord. (From Nigro JJ, Schwartz DS, Bart RD, et al. Neochordal repair of the posterior mitral leaflet.J Thorac Cardiovasc Surg. 2004;127:440-447.)

 

Figure 11.34 Securing the posterior leaflet. (Clip 5, Case 6) 

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POSTERIOR TRICUSPID LEAFLET AUTOTRANSPLANT

Gregori et al. described the use of a portion of the tricuspid valve, a portion of the anterior leaflet in one case, and the whole posterior leaflet in the second case (39). They present longer-term results in 20 patients (40). They report 90% freedom from reoperation, the reoperations were not related to failure of the grafted tricuspid valve. Sixteen of 17 patients evaluated by echocardiography had no or mild mitral regurgitation (Fig. 11.35). These results were confirmed by others (41,42). Given the successful use of artificial chords, this procedure seems unnecessarily complex.

 

Figure 11.35 Technique of grafting a portion of the tricuspid valve to repair the mitral valve. A: Removal of a portion of the anterior leaflet of the tricuspid valve. B: Removal of the posterior leaflet of the tricuspid valve. C: Repair of the anterior leaflet of the mitral valve. D: Repair of the mitral commissure. (A and C: from Gregori Jr. F, da Silva SS, Goulart MP, et al. Grafting of chordae tendineae: a new technique for the repair of mitral insufficiency caused by ruptured chordae of the anterior leaflet. J Thorac Cardiovasc Surg. 1994; 107:635-638. B and D: from Gregori F Jr, Cordeiro CO, Croti UA, et al. Partial tricuspid valve transfer for repair of mitral insufficiency due to ruptured chordae tendineae. Ann Thorac Surg. 1999;68:1686-1691.)

PAPILLARY MUSCLE REPAIR

Papillary muscle rupture can be partial or complete. Partial rupture can present as chronic mitral regurgitation, complete rupture is generally so symptomatic that immediate surgery is required. Acute complete rupture is often associated with extensive infarction and difficult to repair. Repair can be attempted using pledgeted sutures passed through the papillary muscle

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then through the ventricular wall (Fig. 11.36). Partial rupture or rupture of one head can be repaired in the acute or chronic situation by attaching the ruptured head to the adjacent head with pledgeted suture (Fig. 11.37). Fasol et al. demonstrated good results in 6 patients (43).

 

Figure 11.36 Repair of complete rupture by suture to the ventricle. (From Chitwood Jr. WR. Mitral valve repair: ischemic. In: Kaiser LR, Kron IL, Spray TL. Mastery of Cardiothoracic Surgery. Philadelphia: Lippincott-Raven. 1998:318.)

 

Figure 11.37 Repair of rupture of one head of the papillary muscle. (From Muehrcke DD, Cosgrove DM. Mitral valvuloplasty. In: Edmunds, Jr. LH, ed. Cardiac Surgery in the Adult. New York: McGraw-Hill, 1997:1011.)

EDGE-TO-EDGE OR DOUBLE ORIFICE REPAIR

The group headed by Alfieri described, refined, and provided follow-up on the use of the edge-to-edge repair to treat prolapse of one of the mitral leaflets (Fig. 11.38) (44,45,46,47). The overall five-year freedom from reoperation when used with an annuloplasty procedure was 92 ± 3.4% (46). In contrast, Lorusso et al. noted an 80% freedom from reoperation at 8 years (when used alone and with other repair techniques). Risk factors for failure included left ventricular dysfunction, pulmonary arterial hypertension, marked left atrial enlargement, and pericardial annuloplasty (48). Patients with the edge-to-edge repair had smaller valve orifices with no significant stenosis identified (45,49). This has also been applied for poor coaptation in Type IIIB leaflet abnormality (50). Some advocate this over other techniques for its ease of use (51,52). No significant stenosis was created with a combination of the edge-to-edge repair with ring annuloplasty (53).

This repair technique has also been applied via the transaortic approach (Fig. 11.39) (54). This technique has also been applied to eliminate residual regurgitation after the use of traditional repair techniques (55).

LEAFLET REPLACEMENT OR AUGMENTATION WITH PERICARDIUM

Glutaraldehyde-preserved and untreated autologous pericardium has been used to replace or augment leaflets as part of the valve repair (56). For preservation, the pericardium is harvested and treated in 0.62% glutaraldehyde-buffered solution at room temperature for 15 minutes and rinsed in saline for an additional 15 minutes. Techniques include straddling endoven-tricular

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pericardial patch annuloplasty (as discussed above for the severely calcified annulus); patch as a substitute for the posterior leaflet (used to bridge the gap between the leaflet remnants and the annulus); paracommissural extension patch plasty (to fill the commissural area and approximate the two leaflet remnants); posterior leaflet extension patch plasty (to increase the posterior leaflet surface area by more than 50% by inserting a patch between the leaflet and the annulus); patch as substitute for or to enlarge the anterior leaflet (a circular pericardial patch to repair a defect); and chordal replacement (57) (Fig. 11.40). The technique of anterior leaflet extension has recently been recommended as a compliment to myectomy for hypertrophic obstructive cardiomyopathy, the enlarged anterior leaflet moving the point of coaptation away from the septum (58). The gluteraldehyde-treated pericardium has proven to be durable, remains pliable, and does not become excessively calcified (57). Reports using untreated autologous pericardium have produced variable results, often related to shrinkage or calcification of the pericardium (59). Sauvage first reported the use of autologous pericardium in 1966 to augment the surface area or “advance the leaflet” (60,61). Chauvaud et al. reported 64 patients who underwent leaflet extension of the mitral valve between 1980 and 1989 (62). This technique was applied most commonly with regurgitation secondary to rheumatic fever (69%), other causes including bacterial endocarditis (17%), congenital (8%), endomyocardial fibrosis (4.5%), and trauma (1.5%). Follow-up extended from 6 months to 9 years (mean 3.1 ± 2.5 years). Six patients (12%) who underwent reoperation for progression of rheumatic disease; no failures related to the pericardium were noted and there was no evidence of calcification of the pericardial patch. Mitral valve insufficiency was trivial or absent in 80% of the patients.

Kincaid reported a small but encouraging series using anterior leaflet augmentation to compensate for excess posterior leaflet retraction in ischemic mitral regurgitation (Fig. 11.41) (63).

 

Figure 11.38 “Edge-to-edge” repair technique for anterior leaflet prolapse. A: Central stitch to check symmetry. B: Completed running suture creating the repair. C: Side view demonstrating suture placement through the rough zone of the mitral leaflets. (From Maisano F, Schreuder JJ, Oppizzi M, et al. The double-orifice technique as a standardized approach to treat mitral regurgitation due to severe myxomatous disease: surgical technique. Eur J Cardiothorac Surg. 2000;17:201-205.)

 

Figure 11.39 Transaortic approach for edge-to-edge repair. Care must be taken to ensure the suture is placed centrally in both leaflets. (From Kallner G, van der Linden J, Hadjinikolaou L, Lindblom D. Transaortic approach for the Alfieri stitch. Ann Thorac Surg. 2001;71:378-379.)

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Figure 11.40 Various techniques for patching the mitral valve with gluteraldehyde-preserved pericardium. (From Chauvaud S, Jebara V, Chachques JC, et al. Valve extension with glutaraldehyde-preserved autologous pericardium. Results in mitral valve repair. J Thorac Cardiovasc Surg. 1991;102:171-177.)

 

Figure 11.41 Anterior leaflet augmentation for ischemic mitral regurgitation. (From Kincaid EH, Riley RD, Hines MH, Hammon JW, Kon ND. Anterior leaflet augmentation for ischemic mitral regurgitation. Ann Thorac Surg. 2004;78: 564-568).

REFERENCES

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  2. Messas E, Pouzet B, Touchot B, et al. Efficacy of chordal cutting to relieve chronic persistent ischemic mitral regurgitation. Circulation.2003;108 Suppl 1:II;111-115.
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  6. Kron IL, Green R, Cope JT. Surgical relocation of the posterior papillary muscle in chronic ischemic mitral regurgitation. Ann Thorac Surg.2002;74:600-601.
  7. Hvass U, Tapia M, Baron F, Pouzet B, Shafy A. Papillary muscle sling: a new functional approach to mitral repair in patients with ischemic left ventricular dysfunction and functional mitral regurgitation. Ann Thorac Surg.2003; 75:809-811.
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