Asian Cardiovasc Thorac Ann 2007;15:351-358
© 2007 Asia Publishing EXchange Ltd
Mitral Valve Repair: Is There Still a Place for Suture Annuloplasty?
Pino Fundarò, MD,
Paolo M Tartara, MD,
Emmanuel Villa, MD1,
Pasquale Fratto, MD,
Salvatore Campisi, MD,
Ettore O Vitali, MD
Department of Cardiac Surgery, Ospedale Niguarda Cà Granda, Milan
1 Department of Cardiac Surgery, Fondazione Poliambulanza, Brescia, Italy
For reprint information contact: Paolo M Tartara, MD, Tel: 39 02 6444 2565, Fax: 39 02 6444 2566, Email: paolotartara{at}hotmail.com, Division of Cardiac Surgery, Department of Cardiology "A. De Gasperis", Azienda Ospedaliera Niguarda Cà Granda, Piazza Ospedale Maggiore, 3, 20162, Milan, Italy.
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ABSTRACT
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Prosthetic ring annuloplasty is considered the gold standard technique for mitral valve repair, but it has been associated with some drawbacks. Suture annuloplasty is less expensive and may have some physiopathologic advantages. We reviewed the literature to assess clinical results of mitral suture annuloplasty. Thirteen series, each reporting more than 50 patients and published in the last 10 years, were included in the analysis. They comprised 1,648 patients with cumulative follow-up of 5,607 patient-years. Our review suggests that suture annuloplasty is a safe procedure, but a trend toward recurrence of annular dilatation with time was reported. In selected cases, suture annuloplasty is effective, and its mid-term clinical results are encouraging and compare well with those of prosthetic ring repair series. The quality of the results varies according to the particular annuloplasty technique used and to the mitral valve pathology treated. Recent technical modifications have been found to decrease the incidence of repair failure and promise to improve the reproducibility of the procedure. Further investigations are warranted to better assess the long-term results of suture annuloplasty, and to determine whether its theoretical functional advantages translate into a real clinical benefit.
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INTRODUCTION
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Annuloplasty, performed with or without a prosthetic ring, is universally recognized as an essential component of mitral valve repair.1 Suture annuloplasty was first introduced by Lillehei and colleagues2 in the 1950s. Over the last 30 years, due to its reproducibility and excellent long-term results, prosthetic ring annuloplasty has received full acceptance. Currently it is considered the gold standard annuloplasty procedure; nevertheless, some unfavorable pathophysiologic effects of prosthetic rings have been identified in experimental and clinical studies.3–7 Suture annuloplasty has not been abandoned over the years and several potential advantages have been reported.6,8–11 Some notable recent series prompted us to review the literature to assess the current results of suture annuloplasty.6,8–10,12
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CRITERIA, TECHNIQUES, AND TERMINOLOGY
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We analyzed all English language papers listed on PubMed with "mitral valve repair" or "mitral annuloplasty" in the title, and published from 1995 to 2006. The chronological lower limit was chosen to select more comparable studies with regard to recent advances in surgical techniques and postoperative care. Papers were screened by title only. The reference lists were analyzed for additional reports. Predefined criteria for exclusion were papers reporting < 50 patients, mean follow-up < 1 year, and pediatric series. Reports of repair procedures performed by implantation of prosthetic or biological (pericardial) C-shaped bands were excluded; these devices were considered ring-like.
A variety of annuloplasty techniques are described in the literature, and the terms used to describe the procedures are frequently confusing; furthermore, similar techniques are reported with different denominations or author’s name. For these reasons, we grouped suture annuloplasty techniques into 2 main types according to the site of the procedure: commissural area, or mural portion of the annulus. We defined suture annuloplasty as the commissural type if the procedure was in the commisural area. This technique is performed by taking small anchoring suture bites of the anterior annulus at the commissure and progressively larger bites along the adjacent posterior annulus to effectively decrease the length of the posterior annulus.13–15 The second type of annuloplasty is mural annulus shortening. Two subtypes of technique were recognized in this setting, depending on whether the procedure consisted of segmental plication or semicircular reduction performed all along the posterior annulus with running or interrupted sutures.8,16–18 Table 1
summarizes the different procedures and the terminology proposed.
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INCLUDED SERIES
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The complete search provided over 850 topic-related references. Unfortunately, a large number of no-ring repair procedures are frequently included in ring repair series, and these data were not suitable for analysis.19–21 Two studies were published in 2000 and 2006 by the same group;6,12 we included the latter in the analysis. The 13 studies that fulfilled the inclusion criteria were selected for analysis (Table 2). All studies were retrospective. The number of patients ranged from 53 to 341, and the total was 1,648. The mean follow-up ranged from 1.3 to 7 years, with a total cumulative follow-up of 5,607 patient-years. The etiology of mitral valvuloplasty was exclusively degenerative in 5 series. Other series reported ischemic, primary dilated cardiomyopathy, or mixed pathology (Table 2). Semicircular reduction was the most commonly applied technique. Mitral valve repair by suture annuloplasty alone (without other supplemental procedures) was reported for the treatment of secondary mitral regurgitation (MR) in ischemic or advanced idiopathic cardiomyopathy.25–27,30 The series reported by Menicanti and colleagues31 included patients with ischemic dilated cardiomyopathy and severe heart failure undergoing surgical anterior ventricular restoration with mitral valve suture annuloplasty performed through the same ventricular incision.
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EARLY RESULTS
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Perioperative mortality ranged from 0% to 16.6%. As shown in Table 2
, the best results have been reported in degenerative disease, using segmental plication and semicircular reduction techniques.8,10,12,23,24,28 Ischemic, primary dilated cardiomyopathy, and mixed etiologies were associated with higher mortality.22,25,26,29–31 Perioperative morbidity data were not reported in several papers. Residual MR at discharge was reported in 6 series, as the incidence of moderate or severe insufficiency (1% to 16%) or as mean MR grade (0.5–0.7+). Commissural annuloplasty showed less satisfactory relief of mitral incompetence: significant residual MR (grade III–IV) was detected at discharge in 8.6% and 16% of patients.22,26 Semicircular reduction, on the contrary, was associated with lower rates of residual MR of 1% and 2% (mean MR, 0.5–0.7+).12,28,30,31 Early structural repair failures (perioperatively or within 6 months of the operation) were reported in 4 studies. Most series had no early repair failure (Table 2).
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LATE RESULTS
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Actuarial survival at 5–10 years was reported in 8 series (Table 2), with rates of approximately 90% at 5 years, except for patients affected by severe heart failure or ischemic cardiomyopathy.25,26,30
Residual MR (grade 1–3) at follow-up (1.3–7 years) affected 10% to 37% of patients in 9 series (Table 2). However, residual MR has been measured at different follow-up times and reported with different criteria (
mild in 6 series, and moderate in 4). Actuarial freedom from late reoperation varied in the different series (Table 2). Better results have been achieved in recent series with semicircular reduction or segmental plication techniques, especially in degenerative disease.8,10,12,23,24 Most papers reported causes leading to mitral reintervention. At re-operation no recurrent mitral annular dilatation was found in 4 series (Table 2); the reports by the groups of Nagy,28 Komoda,29 Alvarez,23 and Aybek12 had recurrent annular dilatation rates in patients undergoing re-operation of 25%, 36%, 50%, and 100%, respectively. In most cases, recurrent annular dilatation was due to technical failure at the beginning of the experience with mitral suture annuloplasty. Annuloplasty suture breakdown was reported in 2 cases by Nagy and colleagues,28 and in 3 cases by Komoda and colleagues.29
Actuarial freedom from thromboembolic complications was 95.6% at 6 years with a 1.4% per year linearized rate in one series, and 90.4% at 15 years in another.10,23 Nagy and colleagues 28 found a thromboembolic event rate of 0.9% per year per patient. Eisenmann and colleagues24 reported 72.3% freedom from thromboembolic or hemorrhagic events at 8 years, with a linearized rate of 2.3% per year. Actuarial freedom from late infective endocarditis ranged from 96% at 15 years to 100% at 6 and 8 years.10,23,24
At late postoperative Doppler echocardiography, Detter and colleagues6,12 found mean mitral gradients (1.7 mm Hg) to be significantly lower and valve areas (3.3 cm2) significantly larger in patients who had no-ring annuloplasty compared to those who had a ring repair; no difference in mean postoperative MR was found between these 2 groups. Similar valve areas and gradients have been reported with the segmental plication technique by Pomerantzeff and colleagues10 and with the semicircular reduction technique by Nagy and colleagues.28 Hemodynamic data recorded by Odell and colleagues22 after commissural annuloplasty were similar to those found in ring-repaired valves. A recent report of echocardiographic data at discharge and late follow-up (1 and 5 years) showed optimal hemodynamic performance in valves repaired by the semicircular reduction technique, but also a significant trend toward recurrent annular dilatation.12
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DISCUSSION
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There is no ideal annuloplasty technique; one approach is preservation of the physiological annular dynamic, and the other is firm annulus stabilization to prevent progressive post-repair dilation. According to our literature review, suture annuloplasty is currently the preferred or most widely performed surgical technique in only a few centers. Thanks to its reliability, reproducibility, and good long-term results, prosthetic ring annuloplasty is generally the technique of choice for mitral valve repair.32 Rigid and flexible prosthetic rings allow optimal annular stabilization and systolic shape, but some functional disadvantages have been reported: physiological annular dynamic inhibition with posterior leaflet freezing, flattening of the normal annular saddle shape (affecting transmitral flow), systolic anterior motion of the anterior leaflet causing left ventricular outflow tract obstruction, and left ventricular functional impairment.3–5,7,33–39 Moreover, intracardiac prosthetic material is a potential site of thrombus or pannus formation, infection, or hemolysis.19,40–42 Late fibrosis and calcification at the site of ring implantation have been reported in patients re-explored after mitral valve repair.24,42 Another potential disadvantage is the risk of ring dehiscence.43 Use of a prosthetic ring in growing children and in cases of bacterial endocarditis is questionable.20,44 Furthermore, prosthetic ring implantation is more expensive than suture annuloplasty.
Suture annuloplasty is theoretically free from most of these drawbacks: annular leaflet dynamics and left ventricular performance are better preserved.6,11,20,45 This could improve long-term outcome in terms of durability of the valve repair. Moreover, less risk of valve-related complications may be anticipated as insertion of prosthetic material is avoided. Three main questions led to our literature review on suture annuloplasty. Is this technique effective and safe? Is it a long-lasting repair technique? Is there any functional advantage over ring annuloplasty?
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IS SUTURE ANNULOPLASTY SAFE AND EFFECTIVE?
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Today, suture annuloplasty can be considered a safe and effective technique in selected cases. Concerns of the past about increased risk of early structural failure seem to be no longer justified.46,47 Most series reported no early repair failures (Table 2), and as shown by the experience reported by the groups of Alvarez,23 Komoda,29 and Nagy,28 this complication appears now mainly related to avoidable technical errors. Effective annular reduction allowing a tension-free repair of the posterior leaflet and optimal restoration of leaflet coaptation has been reported with segmental plication and semicircular reduction.6,8,10,12,24 Residual MR at discharge was reported in 8 studies (Table 2). Due to the different evaluation criteria used, and the heterogeneity of valve pathology, a comparison between the 3 subtypes of suture annuloplasty seems unreliable. Nevertheless, commissural annuloplasty showed a lower efficacy in relieving MR, probably related to inadequate annular reduction.26,48,49 Four series, one of them not included in our review for chronological reasons, compared the early success rate of suture versus ring annuloplasty.6,22,26,48 Two series comparing commissural annuloplasty with ring repair in mixed and ischemic valve pathology showed a higher rate of early valve repair failure in the suture annuloplasty group.22,48 In the third series comparing commissural with ring annuloplasty in ischemic MR, no difference was found between the two groups.26 The fourth series compared semicircular reduction with Carpentier ring annuloplasty and showed no difference in early residual MR.6
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IS SUTURE ANNULOPLASTY A LONG-LASTING REPAIR TECHNIQUE?
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Suture annuloplasty durability is still the main concern. Except for the report of Alvarez and colleagues,23 only data at medium-term follow-up are currently available, showing acceptable rates of recurrence of MR and freedom from re-operation (Table 2). These results seem to compare well with major ring-repair series (Table 3), but data for a reliable comparison are lacking. Many relevant series pointed out the effectiveness of prosthetic ring annuloplasty in preventing late MR recurrence.21,31,50,54,55 Cohn and colleagues21 and Gillinov and colleagues50 showed a significant advantage of ring annuloplasty repair over no-ring repair in terms of late recurrence of MR; however, their no-ring patients did not receive any type of suture annuloplasty. Unfortunately, few studies have compared ring and suture annuloplasty. David and colleagues54 did not find any significant difference between ring and suture annuloplasty repair (a type of segmental plication) in terms of late valve repair failure. Odell and colleagues22 showed a lower early efficacy in relieving mitral incompetence in patients receiving commissural suture annuloplasty than in those receiving complete or partial ring annuloplasty; however, the late linearized rate of re-operation was better in the suture annuloplasty group (0.29 vs 1.03 per 100 patient-years). Detter and colleagues6 and von Oppell and colleagues26 reported no difference in repair durability in the short to medium term between suture and ring annuloplasty.
As expected, we found that outcomes were strongly affected by the type of valve disease.31,50,56 The best results have been achieved with degenerative valvular pathology limited to the posterior leaflet. Late repair failures occurred mainly in extensively degenerated valves with anterior leaflet prolapse and in ischemic MR. Available data do not determine whether the specific type of suture annuloplasty influences repair durability; nevertheless in more recent series, segmental plication and semicircular reduction in degenerative disease have been associated with optimal results. Commissural annuloplasty showed controversial results.22,25,26,48 The incidence of recurrence of annular dilatation in patients re-operated on for MR following suture annuloplasty varied from 0% to 100% (Table 2). This variability could be due to the differences in suture techniques adopted. Moreover, the cases reported by the groups of Alvarez,23 Komoda,29 and Nagy28 occurred during their initial experience and were mainly related to technical errors. Nevertheless, a higher rate of recurrent annular dilatation at re-operation was recently reported in a large well-studied series, using a tried and tested technique.12 One could point out that the re-operation rate in that series was low (freedom from re-operation was 95.1% at 77 months); however, a significant recurrence of annular dilatation was observed echocardiographically in a very large number of patients with and without residual regurgitation, independent of the valve repair result. This observation is very important, and sustains the major concern about the late durability of suture annuloplasty. On the other hand, it shows us that perhaps there are cases (especially of degenerative disease) in which mitral annuloplasty is not an essential component of the repair procedure.57
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IS THERE ANY FUNCTIONAL ADVANTAGE OVER RING ANNULOPLASTY?
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Few clinical results on functional features are available, but a growing volume of experimental data has been reported in recent years. In an ovine model, Paneth-type annuloplasty relieved MR while simultaneously maintaining normal annular and leaflet dynamic motion.11,17 Similar conclusions were achieved in patients undergoing mitral repair using both Gerbode (segmental plication) and Paneth (semicircular reduction) plasty.58 This could translate into better left ventricular filling, less leaflet and chordal stress, and preservation of physiologic leaflet opening and closing dynamic timing.5,59,60 Hemodynamically, relief of MR can be achieved by suture annuloplasty preserving near physiologic values of mitral valve area and transvalvular gradient.6,10,12,28 Comparing hemodynamic performance at 0, 12, and 24 months postoperatively, Detter and colleagues6 found better valve areas and gradient values in valves repaired by suture (semicircular reduction) rather than ring techniques; mean residual MR was similar in both groups. Unger-Graeber and colleagues20 reached the same conclusion at the early postoperative follow-up. Czer and colleagues48 in an earlier report comparing suture with ring annuloplasty in ischemic MR, similarly found better valve area and gradient values in the first group. On the contrary, Odell and colleagues22 did not find any hemodynamic advantage in suture repair over ring repair of the mitral valve: mitral valve areas and gradients were similar. We could not find any clinical data showing better preservation of postoperative global left ventricular function using suture annuloplasty.
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TECHNICAL SAFEGUARDS
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The best way to perform suture annuloplasty remains undefined. Its reproducibility is far from that of ring annuloplasty. Although some experimental studies provide a rationale for treating the entire annulus, today, only suture annuloplasty procedures limited to the mural and/or the commissural portion of the annulus have been used.61–63 In the adult, segmental plication or semicircular reduction have currently more consensus, and our review supports this conclusion.64,65 Most surgeons have abandoned commissural annuloplasty in adults, but it is still used successfully in pediatric patients.58,59 Some warnings have been stressed in the literature. Aggressive shortening of the mural annulus seems advisable, mainly in commissural annuloplasty.14,48,66 Extensive (> 1.5–2 cm) annular segmental plication should be avoided because of the risk of mitral systolic anterior motion or circumflex artery kinking.12,54 To ensure firm annular stabilization, a series of horizontal mattress non-stretchable sutures passed widely through the atrial wall and then deeply through the annulus has been recommended; polytetrafluoroethylene sutures fulfill these requirements.6,8,12,28,67 Temporary annulus size adjustment using obturators is useful to achieve the correct annular reduction when performing semicircular reduction.18,31,67 The annuloplasty has to be reductive, but attention must be paid to avoiding inflow obstruction due to an excessive pursestring effect (when continuous sutures are used) or by an inappropriate distance between interrupted mattress sutures. To minimize the risk of sutures loosening or tearing through when the tissues are extremely friable, proper reinforcement of the reconstruction with pledgets is recommended, or suture annuloplasty is contraindicated.28,29
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STUDY LIMITATIONS
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Some limitations of our study must be recognized. Firstly, most series comprised a small number of patients. Secondly, formal meta-analysis was precluded by the heterogeneity of the series in terms of techniques employed, patient populations, and data reporting. Finally, most recent reports had limited follow-up and this might mask poor long-term durability of valve repair using suture annuloplasty.
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CONCLUSION
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Suture annuloplasty is still technically not well established, but in our opinion, it should be part of the surgical armamentarium. In particular, segmental plication and semicircular reduction techniques may be safe and valuable options in selected cases of degenerative disease with segmental involvement of the posterior leaflet and limited annular dilatation. Controversial results have been reported with the commissural annuloplasty technique, probably because of the difficulties in obtaining a proper and durable annular reduction by commissure plication. Similarly, controversial results have been published in the setting of ischemic mitral regurgitation. A drawback of suture annuloplasty is its poor reproducibility. Additional experience is needed to standardize the technique, to better assess its long-term efficacy in comparison with ring annuloplasty, and to determine whether its theoretical functional advantages may translate into a real clinical benefit.
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ABSTRACT
INTRODUCTION
