Asian Cardiovasc Thorac Ann 2002;10:344-345
© 2002 Asia Publishing EXchange Pte Ltd
Mitral Annular Reconstruction
Masaru Yoshikai, MD,
Tsuyoshi Ito, MD1,
Junichi Murayama, MD,
Keiji Kamohara, MD
Department of Cardiovascular Surgery Shin-Koga Hospital Kurume City, Fukuoka, Japan
1 Department of Thoracic and Cardiovascular Surgery Saga Medical School Saga City, Saga, Japan
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For reprint information contact: Masaru Yoshikai, MD Tel: 81 942 38 2222 Fax: 81 942 38 2248 e-mail: myoshi{at}toq.ne.jp Department of Cardiovascular Surgery, Shin-Koga Hospital, 120 Tenjin-cho, Kurume City, Fukuoka 830-8577, Japan.
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ABSTRACT
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Mitral annular reconstruction using a pericardial patch was performed in 3 cases of atrioventricular disruption. This technique may be useful for atrioventricular disruption in cases of active endocarditis, redo valve replacement, left ventricular rupture after mitral valve replacement, and annular calcification.
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INTRODUCTION
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Left atrioventricular disruption (AVD) during mitral valve replacement (MVR) can lead to serious complications such as left ventricular (LV) rupture or pseudoaneurysm formation. Disruption of the annulus in active endocarditis poses a technical challenge and necessitates annular reconstruction. This can be carried out using an oval pericardial patch secured to the posterior LV wall and to the left atrial (LA) wall beyond the fragile annular area, covering the AVD (Figure 1A
). Mattress sutures are passed from the patch in the left atrium, through the true annulus if available, and up again into the patch in the left ventricle (Figures 1A and 1B). The sutures are passed through the sewing ring of the prosthesis and tied (Figure 1C). Finally, the edge of the patch in the left atrium is secured to the LA wall (Figure 1D).
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Figure 1. Mitral annular reconstruction after atrioventricular disruption (AVD). (A) A pericardial patch is secured to the left ventricle (LV) and left atrium (LA). (B) Mattress sutures are placed on the patch. (C) The sutures are passed through the sewing ring of the prosthesis and tied. (D) The edge of the patch is secured to the left atrium.
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CASE REPORT
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Case 1
Cardiac examination in a 65-year-old woman revealed severe mitral regurgitation caused by structural failure of a bioprosthetic valve implanted 11 years previously. At reoperation, AVD occurred on the posterior mitral annulus after removal of the prosthesis. Mitral annular reconstruction was performed using an equine pericardial patch (Xenomedica, Edwards Lifesciences AG, Horw, Switzerland). There was no sign of perivalvular leakage or LV pseudoaneurysm development 4 years after the operation.
Case 2
A 72-year-old woman was admitted with active endocarditis. After 3 weeks of medical treatment, growth of vegetation on the posterior mitral leaflet indicated emergency surgery. At operation, the infection was found to extend to the posterior annulus. Resection of the infected annular tissue resulted in AVD, so annular reconstruction was performed with autologous pericardium. The patient was doing well 4 years postoperatively, with no sign of recurrence of infection or perivalvular leakage.
Case 3
A 57-year-old man who had undergone MVR with a mechanical valve 16 years previously, was admitted with active endocarditis. Three weeks later, regurgitation from around the prosthesis appeared and gradually worsened. During an emergency operation, it was found that the prosthesis had become detached from almost the entire posterior annulus because of infection. After removal of the prosthesis and fragile infected annular tissue, the annular area was covered with equine pericardium, and a new prosthesis was implanted. The infection subsided, and no perivalvular leakage was detected on echocardiography. However, the patient died from multiorgan failure 30 days after the operation.
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DISCUSSION
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The posterior mitral annulus is fragile and easily damaged.1 While it is necessary to restore the annular structure for MVR, annular tissue may be already damaged or at high risk of surgical injury. In active endocarditis, infected tissue or an abscess should be completely resected to prevent recurrence. Aggressive debridement of the annular tissue may create AVD and leave no firm tissue on which to secure the prosthesis. In redo MVR, the proper excision plane of the prosthesis is between the metal and the sewing ring.2 However, the tip of a knife pointing toward the posterior annulus could injure the annulus. Moreover, adhesion of a bioprosthesis to the LV wall makes dissection more difficult, and improper dissection can lead to LV rupture. In type-I LV rupture after MVR, suture closure is usually unsuccessful. An endocardial repair is the ideal procedure, covering not only the LV myocardium around the tear but also the annulus and the LA wall.2
Marked annular calcification makes it difficult to insert a prosthesis. Carpentier and colleagues3 removed the strip of calcification during valve repair with good results, but some surgeons have expressed concern about the inherent risk of AVD. We prefer to cover the fragile portion of the annulus with pericardium after removal of the calcification. When AVD occurs or the fragile annular tissue is exposed, mitral annular reconstruction should be performed.4 The essence of this procedure is to cover all the fragile tissue around the annulus and make a firm structure on which to secure the prosthesis. We modified the annular reconstruction method of David and colleagues.4 David5 experienced a tear in a bovine pericardial patch, which needed reoperation, so we placed horizontal mattress sutures through the patch in securing the prosthesis, to obtain firmer fixation. Our experience with this annular reconstruction method is limited to 3 cases, however, no patient experienced a complication such as LV rupture, LV pseudoaneurysm, infection recurrence, or valve dehiscence. This procedure is indicated for AVD or a fragile annulus affected by active endocarditis, redo MVR, LV rupture after MVR, and annular calcification.
Presented at the 7th Annual Meeting of the Asian Society for Cardiovascular Surgery, Singapore, May 28–31, 1999.
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REFERENCES
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- McAlpine WA. The mitral valve: heart and coronary arteries. Berlin, Heidelberg, New York: Springer-Verlag, 1975:39–56.
- Reardon MJ, Letsou GV, Reardon PR, Baldwin JC. Left ventricular rupture following mitral valve replacement. J Heart Valve Dis
1996;5:10–5.[Medline]
- Carpentier AF, Pellerin, Fuzellier JF, Relland JYM. Extensive calcification of the mitral valve anulus: pathology and surgical management. J Thorac Cardiovasc Surg
1996;111:718–30.[Abstract/Free Full Text]
- David TE, Feindel CM, Armstrong S, Sun Z. Reconstruction of the mitral annulus. A ten-year experience. J Thorac Cardiovasc Surg
1995;110:1323–32.[Abstract/Free Full Text]
- David TE. The use of pericardium in acquired heart disease: a review article. J Heart Valve Dis
1998;7:13–8.[Medline]
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ABSTRACT
INTRODUCTION
