Atlas of Mitral Valve Repair, 1st Edition

9

Posterior Leaflet Repair Techniques

POSTERIOR LEAFLET PLICATION

As the leaflets degenerate and become stiff and redundant with no clear major abnormalities that can be identified, the source of the leak may be attributable to incomplete closure of posterior leaflet clefts. This can result from redundancy or stiffness. A solution is to close the cleft by simple plication to reestablish the coaptive surface of the posterior leaflet (Figs. 9.1,9.2,9.3). This technique can also be used to exclude a prolapsing scallop or treat a posterior chordal rupture (1) (Fig. 9.4).

 

Figure 9.1 Posterior leaflet plication. (From Seccombe JF, Schaff HV. Mitral valve repair: current techniques and indications. In: Franco KL, Verrier ED, eds.: Advanced Therapy in Cardiac Surgery. St. Louis: B.C. Decker, 1999:224.)

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Figure 9.2 Cleft closure and lateral commissuroplasty. (Clip 6, Case 3) 

 

Figure 9.3 Cleft closure after posterior sliding plasty. (Clip 7, Case 1) 

QUADRANGULAR RESECTION

One of the simplest and most commonly applied resection approaches is a quadrangular resection. The prolapsing portion of the leaflet is excised as a quadrangle to the annular level. The incision should be made in hardy tissue that will hold sutures well. The leaflets are then reapproximated with a running suture between the leaflet edges continuing to fold together the annular cut edges. The atrial portion can be reinforced with a pledgeted suture (Fig. 9.5). Suturing is started at the leaflet edge with a simple suture tied on the ventricular side of the valve that is brought through to the atrial side to pull the edge under (Fig. 9.6).

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This is then run as two layers in a running locking fashion (Fig. 5.6), reapproximating the cut edges of the leaflet taking care not to bunch up and foreshorten the leaflet. A second suture at the annulus pulls together the two cut edges at the annular level and the first suture is tied to this second, completing the leaflet reapproximation. This is then run to the apex of the annular fold and tied to a third anchoring suture. Completion of this repair may pull open a previously occlusive cleft between scallops, requiring simple closure with a figure-of-eight suture.

 

Figure 9.4 Posterior plication to treat a ruptured chord. C: View of the underside of the leaflet. (From McGoon DC. An early approach to the repair of ruptured mitral chordae.Ann Thorac Surg. 1989;47:628-629.)

 

Figure 9.5 Quadrangular resection.

 

Figure 9.6 Suture technique for quadrangular resection. The first of two layers is shown. A: Suture placed at the edge of the leaflets. B: Suture placed at the base of the annular plication. C: Suture placed at the apex of the annular plication.

 

Figure 9.7 Quadrangular resection of the P2 scallop of the posterior leaflet. (Clip 2, Case 6) 

An alternative to excising the leaflet scallop is to fold down and plicate the redundant tissue. This is useful when the tissue is weak because there is more tissue to hold sutures in place (Figs. 9.7 and 9.8).

TRIANGULAR RESECTION

Seccombe and Schaff described a preference for triangular resection of the posterior leaflet for prolapse and redundancy of a large portion of the posterior leaflet (2). They felt this method placed less stress on the suture line and created less annular distortion (Fig. 9.9).

 

Figure 9.8 Excision of the P2 scallop based on the location of intact chords. (Clip 3, Case 1) 

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Figure 9.9 Posterior triangular resection. (From Seccombe JF, Schaff HV. Mitral valve repair: current techniques and indications. In: Franco KL, Verrier ED, eds. Advanced Therapy in Cardiac Surgery. St. Louis: B.C. Decker, 1999:225.)

SLIDING LEAFLET PLASTY

If the height of the posterior leaftlet after quadrangular resection is too high (> 20 mm), there is an incidence of left ventricular outflow tract obstruction secondary to systolic anterior motion (See Chapter 12). To avoid this complication, Carpentier developed the sliding leaflet technique to remove excess tissue and preserve geometry (3). Perier et al. evaluated this technique in 48 patients with excellent results and no systolic anterior motion (SAM) (4).

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Gillinov et al. recommend this technique be used instead of plication if the posterior leaflet excised is more than 1.5 centimeters (5) (Figs. 9.10,9.11,9.12).

 

Figure 9.10 Sliding leaflet technique. (From Perier P, Clausnizer B, Mistarz K. Carpentier “sliding leaflet” technique for repair of the mitral valve: early results. Ann Thorac Surg. 1994;57:383-386.) A: A quadrangular resection of the diseased scallop is performed. B: The remaining posterior leaflet is detached from the annulus. C: Sutures are passed through the posterior annulus in a parallel orientation; the free edges of the leaflets are reapproximated. D: The leaflet is sewn to the annulus with a 4-0 monofilament and the leaflets reapproximated with 5-0 monofilament. E: The ring is secured in place.

 

Figure 9.11 Mobilization of the posterior leaflet. (Clip 4, Case 1) 

 

Figure 9.12 Reattachment of posterior leaflet creating a posterior sliding plasty. (Clip 5, Case 1) 

A variant of this technique is described by Gillinov and Cosgrove for asymmetric leaflets in which one side is taller than the other because the quadrangular resection leaves leaflets of varying heights (6) (Figs. 9.13 and 9.14).

 

Figure 9.13 Modified sliding leaflet repair. (From Gillinov AM, Cosgrove DM. Modified quadrangular resection for mitral valve repair. Ann Thorac Surg. 2001;72:2153-2154.)

 

Figure 9.14 Leaflet rotation to increase leaflet height. (From Gillinov AM, Cosgrove DM. Modified quadrangular resection for mitral valve repair. Ann Thorac Surg. 2001; 72:2153-2154.)

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Figure 9.15 Posterior folding plasty. (From Spencer FC, Galloway AC, Grossi EA, et al. Recent developments and evolving techniques of mitral valve reconstruction. Ann Thorac Surg. 1998;65:307-313.)

 

Figure 9.16 Posterior folding plasty. (Clip 4, Case 7) 

POSTERIOR FOLDING PLASTY

Another approach for a large redundant posterior leaflet is the posterior folding plasty described by Spencer et al. (7) (Figs. 9.15 and 9.16). Raman et al. described a variant of this procedure, which they called the double-breasted repair, and reported its application in 36 patients (8). In comparing this with standard quadrangular resection using annular plication they noted lower transmitral gradients (Fig. 9.17).

LEAFLET AUGMENTATION OR ADVANCEMENT

(See Chapter 11.)

REMOVAL OF ANNULAR CALCIFICATION

Debridement and Primary Closure

Described in 12 patients in 1991, debridement and primary closure involves extensive resection of the calcium with reconstruction of the annulus, using established methods of repair (9). This experience was updated by Carpentier et al. in 1996 (10). Reviewing 68 patients, they noted the calcification process was localized to the annulus

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in 77% but could extend to the underlying myocardium. They fixed the valve by detaching of the leaflets, en bloc resection of the calcium deposit, annular reconstruction, and valve repair. If the calcification extended into the myocardium a sliding atrioplasty of the left atrium was performed. Actuarial freedom from reoperation was 87% at 7 years. They describe four differing degrees of calcification in the ventricle and leaflet (Fig. 9.18) in addition to various distribution patterns around the annulus. First the posterior leaflet is detached and the calcium removed by sharp dissection (Fig. 9.19). The annular defect is then closed with figure-of-eight 2-0 vertical sutures (Fig. 9.20). Stressing that “the ventricular bites of these sutures should involve only one third of the thickness of the myocardial wall and be as wide as possible, taking advantage of any fibrous tissue present on the surface of the endothelium.”

 

Figure 9.17 Double-breasted mitral valve repair. (From Raman JS, Gupta R, Shah P, Setty R, Tambara K. Double-breasted repair of the posterior mitral valve leaflet. Ann Thorac Surg. 2002;74:2206-2207.)

 

Figure 9.18 Ventricle and leaflet calcification patterns of the mitral annulus. (From Carpentier AF, Pellerin M, Fuzellier J, Relland JYM. Extensive calcification of the mitral valve annulus: pathology and surgical management. J Thorac Cardiovasc Surg. 1996;111:718-730.)

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Figure 9.19 Annular decalcification. (From Carpentier AF, Pellerin M, Fuzellier J, Relland JYM. Extensive calcification of the mitral valve annulus: pathology and surgical management. J Thorac Cardiovasc Surg. 1996;111:718-730.)

If the defect extends far down into the myocardium he advocates the sliding atrium technique to repair it (Fig. 9.21). This technique moves the atrial wall into the ventricle to cover the defect and relocates the valve attachment point onto the atrial wall.

The leaflets are then reattached and an annuloplasty ring is placed with the sutures close to the annular defect (Fig. 9.22).

Debridement and Pericardial Patch Closure

David et al. described a similar approach to the one described above, patching the defect with pericardium instead of using primary repair (11) (Fig. 9.23). He also applied this technique for annular destruction by endocarditis.

Using a combination of these techniques in 37 patients, Ng et al. reported 1- and 5-year freedom of reoperation rates of 94.6% (12). Thirty-three had no to trivial regurgitation, and 3 had grade I-II regurgitation at follow-up. Similar results have been reported by other authors (13,14).

 

Figure 9.20 Repair of annular defect with vertical 2-0 figure-of-eight sutures. (From Carpentier AF, Pellerin M, Fuzellier J, Relland JYM. Extensive calcification of the mitral valve annulus: pathology and surgical management. J Thorac Cardiovasc Surg. 1996;111:718-730.)

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Figure 9.21 Sliding atrium technique. (From Carpentier AF, Pellerin M, Fuzellier J, Relland JYM. Extensive calcification of the mitral valve annulus: pathology and surgical management. J Thorac Cardiovasc Surg. 1996:111:718-730.)

 

Figure 9.22 Reattaching the posterior leaflet. (From Carpentier AF, Pellerin M, Fuzellier J, Relland JYM. Extensive calcification of the mitral valve annulus: pathology and surgical management. J Thorac Cardiovasc Surg. 1996;111: 718-730.)

 

Figure 9.23 Annular reconstruction with pericardial patch. (From David TE, Feindel CM, Armstrong S, Sun Z. Reconstruction of the mitral annulus. A ten-year experience. J Thorac Cardiovasc Surg. 1995;110(5):1323-1332.)

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REFERENCES

  1. McGoon DC. An early approach to the repair of ruptured mitral chordae. Ann Thorac Surg.1989;47:628-629.
  2. Seccombe JF, Schaff HV. Mitral valve repair: current techniques and indications. In: Franco KL, Verrier ED, eds. Advanced Therapy in Cardiac Surgery.St. Louis: B.C. Decker. 1999:220-231.
  3. Carpentier A. The sliding leaflet technique. Le Club Mitrale Newsletter1998;I-5.
  4. Perier P, Clausnizer B, Mistarz K. Carpentier “sliding leaflet” technique for repair of the mitral valve: early results. Ann Thorac Surg.1994;57:383-386.
  5. Gillinov AM, Cosgrove DM. Mitral valve repair for degenerative disease. J Heart Valve Dis.2002;11 Suppl 1:S15-20.
  6. Gillinov AM, Cosgrove DM. Modified quadrangular resection for mitral valve repair. Ann Thorac Surg.2001;72: 2153-2154.
  7. Spencer FC, Galloway AC, Grossi EA, et al. Recent developments and evolving techniques of mitral valve reconstruction. Ann Thorac Surg.1998;65:307-313.
  8. Raman JS, Gupta R, Shah P, Setty R, Tambara K. Double-breasted repair of the posterior mitral valve leaflet. Ann Thorac Surg.2002;74:2206-2207.
  9. el Asmar B, Acker M, Couetil JP, et al. Mitral valve repair in the extensively calcified mitral valve annulus. Ann Thorac Surg.1991;52:66-69.
  10. Carpentier AF, Pellerin M, Fuzellier J, Relland JYM. Extensive calcification of the mitral valve annulus: pathology and surgical management. J Thorac Cardiovasc Surg.1996;111:718-730.
  11. David TE, Feindel CM, Armstrong S, Sun Z. Reconstruction of the mitral annulus. A ten-year experience. J Thorac Cardiovasc Surg.1995;110(5):1323-1332.
  12. Ng CK, Punzengruber C, Pachinger O, et al. Valve repair in mitral regurgitation complicated by severe annulus calcification. Ann Thorac Surg.2000;70:53-58.
  13. Fasol R, Mahdjoobian K, Joubert-Hubner E. Mitral repair in patients with severely calcified annulus: feasibility, surgery, and results. Heart Valve Dis.2002;11:153-159.
  14. Grossi EA, Galloway AC, Steinberg BM, et al. Severe calcification does not affect long-term outcome of mitral valve repair. Ann Thorac Surg.1994;58:685-687.