Asian Cardiovasc Thorac Ann 2003;11:83-84
© 2003 Asia Publishing EXchange Ltd
Mitral Annuloplasty With Autologous Pericardium and Saphenous Vein
Pratap K Paruchuru, FRCSEd,
Krishna Adluri, FRCS1,
Aiman Alzetani, FRCS1,
Ramesh Patel, FRCSEd(CTh)1
Department of Cardiothoracic Surgery, North Staffordshire Royal Infirmary, Stoke-on-Trent, England, UK
1 Department of Cardiothoracic Surgery, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, England, UK
For reprint information contact: Pratap K Paruchuru, FRCSEd Tel: 44 1782 71 5444 Fax: 44 1782 55 4830 email: ppkumar{at}rcsed.ac.uk Department of Cardiothoracic Surgery, North Staffordshire Hospital, Royal Infirmary, Princes Road, Harts Hill, Stoke-on-Trent, Staffs ST4 7LN, UK.
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ABSTRACT
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Two techniques for constructing annuloplasty rings at the time of surgery are described, using great saphenous vein and autologous pericardium. These rings are easy to make and offer a no-cost alternative to commercially available rings. The long-term performance of such rings has not been determined.
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INTRODUCTION
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Mitral valve repair is well established as a reliable technique for surgical correction of mitral regurgitation of various etiologies. In almost all patients, it is necessary to perform annuloplasty using one of the various commercially available rings to stabilize the repair and correct and prevent further annular dilatation. Biological materials have been used to construct annuloplasty rings with successful results.1,2 We describe two methods of constructing annuloplasty rings from great saphenous vein and autologous pericardium. These rings are easy to make intraoperatively and provide a good no-cost alternative to the expensive commercial rings.
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TECHNIQUE
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SAPHENOUS VEIN RING
Approximately 10 cm of saphenous vein is harvested. The size of the annulus is ascertained using the standard sizers for any of the commercially available annuloplasty rings. The circumference of the sizer is measured using a silk suture. The unstretched saphenous vein is tailored to match the length of this suture. The vein is turned inside out to exteriorize the endothelial surface. The vein is mounted on the sizer, and the ends are approximated using 4/0 Proline (Ethicon, Somerville, NJ, USA) to complete the ring. The commissures are marked with 4/0 Proline sutures, and the ring is sutured to the annulus using interrupted mattress sutures. However, tying the knots in sequence can be cumbersome and the ring may wrinkle when tying down the knots. Gentle traction on the mattress sutures on either side before tying the knot helps overcoming this problem.
PERICARDIAL RING
Following midline sternotomy, a rectangular patch of pericardium, approximately 10 cm long and 5 cm wide is harvested after clearing the fat from its surface. The ends of the pericardial patch are held with 4/0 Proline sutures at the 4 corners. The patch is rolled over a 2-mm probe so that the visceral surface remains outside. The sutures are tied at 1- to 2-cm intervals to keep the roll intact and maintain uniformity of thickness. The ties also serve as markers during insertion of the ring. The size of the annulus is determined, and the pericardial roll is cut to the appropriate size. The pericardial roll is ready for use either as a complete ring (as described above) or as an incomplete ring using the same technique as for the saphenous vein ring.
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DISCUSSION
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Use of autologous tissue for constructing annuloplasty rings has been described before. It has been shown that the use of biological rings for annuloplasty improves mitral annular dynamics and hence the long-term outcome.3 In the presence of active endocarditis, these techniques provide a good alternative to conventional rings because prosthetic material may increase the risk of infection. Over a 2-year period, 9 such rings were used in our institution: 7 to repair infected valves, and 2 for annuloplasty following extensive decalcification of the posterior annulus. There was no hospital mortality and echocardiograms prior to discharge of the patients demonstrated satisfactory mitral valve function and no significant mitral regurgitation.
One disadvantage of such rings is that they are flaccid and shapeless when used as complete rings, and they may eventually assume a round shape. To overcome this problem, some authors have advocated not anchoring the ring at the commissural level and excising the unanchored portion, which may help preserve the geometry of the annulus.1 The ease of preparation and low cost makes them an attractive alternative to their commercially available expensive counterparts, which will have implications in the developing world. They have been used successfully, especially in redo operations and in operations for endocarditis, with early good results in our institution. The autologous tissue of the ring provokes a minimal immune response, and consequently late calcification would be expected to be much slower although unavoidable. However, the long-term performance of these rings needs to be assessed.
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REFERENCES
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- Shatapathy P, Agarwal BK, Kamath SG. Mitral valve repair: the Manipal alternative. J Heart Valve Dis
2000;9:487–94.[Medline]
- Komoda T, Hubler M, Siniawski H, Hetzer R. Annular stabilization in mitral repair without a prosthetic ring. J Heart Valve Dis
2000;9:776–82.[Medline]
- Borghetti V, Campana M, Scotti C, Domenighini D, Totaro P, Coletti G, et al. Biological versus prosthetic ring in mitral valve repair: enhancement of mitral annulus dynamics and left ventricular function with pericardial annuloplasty at long term. Eur J Cardiothorac Surg
2000;17:431–9.[Abstract/Free Full Text]
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ABSTRACT
INTRODUCTION
