Asian Cardiovasc Thorac Ann 2008;16:495-496
© 2008 Asia Publishing EXchange Ltd
Simple Suture Mitral Annuloplasty with Left Ventriculotomy
Mohammad H Mandegar, MD,
Mohammad A Yousefnia, MD,
Farideh Roshanali, MD
Division of Cardiac Surgery, Day General Hospital, Tehran, Iran
For reprint information contact: Farideh Roshanali, MD Tel: 98 912 309 3151 Fax: 98 21 8879 7353 Email: farideh_roshanali{at}yahoo.com, No.1, 8th Floor, 15th Tower, Hormozan St., Ghods Shahrak, Tehran, 14466, Iran.
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ABSTRACT
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Surgical treatment of mitral regurgitation, especially when compounded by ventricular aneurysm, remains a challenge. Several procedures have been developed to repair the mitral valve and reduce regurgitation. We describe a technique of intraventricular annuloplasty which is much less time-consuming than mitral valve repair through a left atriotomy. This procedure is considered technically easy and useful.
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INTRODUCTION
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Mitral regurgitation exacerbated by left ventricular (LV) aneurysm requires complex and time-consuming surgical interventions, such as aneurysm resection, LV reconstruction and coronary bypass. Mitral repair carried out via a left atriotomy prolongs surgery. In such situations, it is feasible to perform intraventricular annuloplasty.
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TECHNIQUE
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Surgery is performed through a median sternotomy with standard cardiopulmonary bypass (nasopharyngeal temperature, 28°C), and antegrade and retrograde cold blood cardioplegia. The left ventricle is incised, and any clot in the apex or aneurysm is drained. The LV free wall and septum as well as the site of the sutures that will later exclude the aneurysm are inspected. The pathology of the mitral valve is determined by perioperative transesophageal echocardiography. The mitral valve is clearly visible through the extensively dilated ventricle. It is possible to insert the annuloplasty sutures either precisely on the ventricular surface of the posterior annulus or on the surface of the atrium from commissure to commissure (trigone to trigone), as in the classic procedure. It has to be mentioned that our technique precludes the possibility of using a saline test to investigate mitral regurgitation; consequently, the patient must come off the pump and undergo transesophageal echocardiography.
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DISCUSSION
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This technique was applied in 5 symptomatic men (mean age, 59.6 ± 7.6 years) with severe mitral regurgitation and an aneurysm involving the LV anterior wall, due to an anterior myocardial infarction caused by occlusion of the left anterior descending artery. The technique used in all cases was endoventricular patch repair with ventriculoplasty reshaping. The aneurysm was opened parallel to the left anterior descending coronary artery, and the papillary muscles were inspected. It is noteworthy that if the distance between the papillary muscles is 2.5 cm more than in the previous echocardiogram, papillary muscle approximation or another procedure for subvalvular components can also be performed. The mid portion of the posterior leaflet was retracted with a 5/0 Prolene suture, and a retractor was positioned inside the anterior leaflet to expose the posterior annulus (Figure 1
). A pericardium-pledgetted 3/0 Gore-Tex suture was used to place 2 rows of continuous suture, from trigone to trigone, through the atrial surface of the mitral valve and onto the posterior annulus for reinforcement (Figure 2). The use of 3/0 Gore-Tex suture was solely to avoid future stretching. A patch was sutured with 3/0 Prolene onto the firm tissue of the transitional zone, so that the scar was almost completely excluded from the LV cavity. The ventricle was closed with Teflon-reinforced sutures. LV aneurysm resection was carried out after completing the distal anastomosis. Echocardiography at discharge did not detect tethering of the mitral valve or regurgitation. Coaptation, which had been dislocated toward the apex preoperatively, reverted to the original level of the mitral annulus. Echocardiography at 6 months showed no or trivial regurgitation.
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Figure 1. The retractor positioned inside the anterior leaflet to give it sufficient traction and expose the posterior annulus. LA = left atrium, LV = left ventricle.
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Figure 2. Suture annuloplasty from trigone to trigone through the atrial surface of the mitral valve and onto the posterior annulus. LA = left atrium, LV = left ventricle.
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Mitral valve function may be improved by aneurysm repair and surgical remodeling of the ventricular cavity, but severe insufficiency necessitates mitral valve repair or replacement. Patients with LV aneurysm have a high risk of ischemic mitral regurgitation. The operative mortality of LV aneurysm repair is 8%, but associated mitral valve repair can increase this.1 We experimented with intraventricular suture annuloplasty as a simple alternative to mitral valve repair via atriotomy. Intraventricular mitral plication suturing is a simple, reproducible, and cheap technique, with acceptable results. Use of a strong non-stretchable suture is essential for good results. Polytetrafluoroethylene (Gore-Tex) suture fulfills the requirements for annuloplasty.2 A limitation of this method is that it can only be applied in cases requiring simultaneous ventriculoplasty for LV remodeling.
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REFERENCES
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- Tavakoli R, Bettex D, Weber A, Brunner H, Genoni M, Pretre R, et al. Repair of postinfarction dyskinetic LV aneurysm with either linear or patch technique. Eur J Cardiothorac Surg 2002;22:129–34.[Abstract/Free Full Text]
- Nagy ZL, Péterffy A. Mitral annuloplasty with a suture technique. Eur J Cardiothorac Surg 2000;18:739–41.[Free Full Text]
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ABSTRACT
INTRODUCTION
