Asian Cardiovasc Thorac Ann 1998;6:158-161
© 1998 Asia Publishing EXchange Pte Ltd
Mitral Valvuloplasty With Carpentier's Techniques
Phan Nguyen Van, MD,
Phuong Phan Kim, MD,
Vinh Pham Nguyen, MD ,
Yen Dang Thi Bach, MD,
Trung Dao Huu, MD,
Hiep Chu Trong , MD,
Quy Nguyen Thi, MD,
Hào Nguyen Tiên , MD,
Alain Deloche, MD, PhD ,
Alain Carpentier, MD, PhD
|
Heart Institute Ho Chi Minh City, Vietnam
|
|
Phan Nguyen Van, MD Heart Institute 520 Nguyen Tri Phuong Ho Chi Minh City, Q10, Vietnam Tel: 84 8 865 1586 Fax: 84 8 865 1543
|
 |
ABSTRACT
|
|---|
From January 1992 to January 1997, 586 patients with mitral incompetence were treated by Carpentier's techniques in the Heart Institute of Ho Chi Minh City, Vietnam. Ages ranged from 6 to 60 years (mean, 26.4 ± 9.9 years) and 124 patients were younger than 15 years of age. Mitral valve incompetence was classified into three types according to leaflet pliability: type I, normal leaflet motion, 7 cases (1.2%); type II, leaflet prolapse, 185 cases (31.6%); type III, restricted leaflet motion, 394 cases (67.2%). Associated tricuspid valvular disease was present in 337 cases (57.5%). Mitral valve prosthetic ring annuloplasty was used in 532 cases (90.8%). The operative mortality rate was 1.9% (11/586). According to the New York Heart Association functional classification, 3.9% (23/586) of the patients were in class I, 52% (305/586) were in class II, 42.3% (248/586) were in class III, and 1.7% (10/586) were in class IV. Mitral valve disease was due to rheumatic fever in 96.7% of the patients. Follow-up data were available in 572 patients from 1 year to 5 years (mean, 38 months). The late mortality rate was 0.7% (4/572). Morbidity comprised endocarditis in 2 patients, one patient had a cerebral hemorrhage, and 16 patients underwent reoperation for recurrent mitral incompetence (incorrect operative indication). There were 2 incidents of thromboembolism. Patient selection was based on valvular disease rather than age, physical condition, or cause of valvular disease. The low mortality and complication rates in this series confirm that mitral valve reconstruction by Carpentier's techniques was appropriate for the patients with mitral incompetence, particularly for children.
|
INTRODUCTION
|
|---|
Reconstructive surgery on the mitral valve has improved during the past 30 years. Many long-term evaluations have shown excellent results and mitral valve pathology is now approached with a view to preservation of the native valve. Among the 3955 patients who were operated on at our institute in the last 5 years, 1123 underwent valve repair. The feasibility of repair now extends to approximately 90% of cases of mitral incompetence and it is particularly appropriate in children. This is a retrospective study of 586 patients with mitral insufficiency who underwent mitral valve repair. Excluded from this study were 22 cases of congenital mitral valve disease, 537 cases of pure mitral valve stenosis, and 310 cases of combined aortic and mitral valve disease.
|
PATIENTS AND METHODS
|
|---|
From January 1992 to January 1997, 586 patients with mitral valve incompetence were treated by Carpentier's techniques of mitral valve reconstruction at the Heart Institute, Ho Chi Minh City, Vietnam. The patients' ages ranged from 6 to 60 years (mean, 26.4 ± 9.9 years) and 124 of them were below 15 years of age. There were 198 males and 388 females. Cardiothoracic ratios ranged from 0.5 to 0.85 (mean, 0.64 ± 0.08). According to the New York Heart Association functional classification, 23 patients (3.9%) were in class I, 305 (52%) were in class II, 248 (42.3%) were in class III, and 10 (1.7%) were in class IV. There were 245 patients (41.8%) in sinus rhythm and 341 patients (58.2%) in atrial fibrillation. The causes of mitral valve disease are listed in Table 1
. Of note is the prevalence of rheumatic valvular disease (96.7%) and the very low incidence of degenerative valvular disease. This is a significant characteristic of heart valve disease in Vietnam.
Mitral valve incompetence was classified into 3 types depending on leaflet pliability according to Carpentier's physiopathological classification (Table 2).1–3 Type I, normal leaflet motion: the free edges of the leaflets remain below the plane of the annulus during systole and open normally during diastole; the incompetence is caused by noncoaptation of the leaflet. Type II, leaflet prolapse: the free edge of one or both leaflets overrides the plane of the annulus during systole; in our study, 185 patients were classified as having this type. Prolapse can occur in one or both leaflets. Type III, restricted leaflet motion: one or both leaflets do not open fully during diastole; this was the most common functional anomaly in our study (67.2%). We noted that in rheumatic valvular disease, restricted motion of the posterior leaflet was usually associated with a slight prolapse of the anterior leaflet. The classification could be further defined according to the primary lesion. The lesions responsible for functional disorders are listed in Table 3. The sum of the lesions is greater than the number of patients because multiple associated lesions were common. When associated lesions were present, the predominant lesion served to classify the patient.1
SURGICAL TECHNIQUES
The surgical procedures are listed in Table 4. Carpentier's prosthetic ring was necessary in approximately 90% of patients irrespective of the functional type of the mitral disease. Several techniques were required in type II disease. Quadrangular resection of the posterior leaflet was performed in cases of rupture of the chordae of the posterior leaflet. If chordal rupture occurred in the anterior leaflet, the preferred method was transposition of the chordae. We transferred secondary chordae from the posterior leaflet or even from the anterior leaflet tothe position of the ruptured chordae. Cases of chordal elongation were treated by shortening of the relevant chordae. Leaflet prolapse was also due to papillary muscle elongation. For this lesion, we preferred to use the papillary muscle shortening method.
Multiple techniques were employed in type III disease. These included resection of the secondary chordae attached to the ventricular surface of the base of the leaflet, which are a major cause of restricted leaflet motion.2 Fenestration of chordae was also undertaken by removing a triangular wedge of fibrous tissue so as to mobilize the leaflet and release the subvalvular stenosis.2 One of the frequently occurring lesions in rheumatic valvular disease is leaflet retraction, particularly in children. This lesion is caused by a lack of leaflet tissue. Valve extension with glutaraldehyde-preserved autologous pericardium is a solution to this problem. This technique allowed the use of a ring larger than would have been possible without extension.4 The size of the ring was selected according to the size of the repaired anterior leaflet. Patching techniques depend on the site and extent of the lesion (Figure 1). The average number of procedures for each patient was 2.9. Tricuspid disease, usually functional tricuspid insufficiency, is often associated with mitral disease. The procedures used for tricuspid valve repair are listed in Table 5.
Follow-up data was obtained by consultations at theHeart Institute. Follow-up investigations included clinical examination, electrocardiography, and Doppler echocardiography. Doppler echocardiography was carriedout every 3 months in the first postoperative year and every 6 months thereafter. Only 3 patients were lost to follow-up.
|
RESULTS
|
|---|
There were 11 hospital deaths giving a mortality rate of 1.9%. The causes of early death were heart failure in 7 patients, septic shock in 3, and cardiac tamponade in 1. There were 4 late deaths (0.7%) among the 572 patients who were followed up from 1 to 5 years (average duration of follow-up was 38 months). The actuarial survival rate was 98% ± 0.6% at 5 years.
In addition to the 4 late deaths, 20 patients suffered nonfatal complications. Two patients has bacterial endocarditis 1 year postoperatively, which was controlled by medical treatment. Two patients suffered thrombolic events. Sixteen patients required reoperation for valve replacement within the first 2 years. The reasons for reoperation were ring dehiscence in 2, residual prolapse in 3, recurrent prolapse in 1, leaflet retraction in 5, and hemolysis in 4. The actuarial freedom from reoperation at 5 years was 95.79% ± 1.32%.
Assessment of mitral regurgitation was carried out by auscultation and Doppler echocardiography. No systolic murmur was present in 528 patients (90.1%); 43 patients (7.3%) had a mild systolic murmur that was noted immediately after the operation and remained unchanged. Doppler echocardiography was carried out in 572 patients of whom 499 (87.2%) had no or mild regurgitation, 61 (10.7%) had moderate regurgitation, and there were only 12 patients (2.1%) who had severe regurgitation. These 12 patients were among the 16 who underwent reoperation for valve replacement.
|
DISCUSSION
|
|---|
The incidence of rheumatic valvular disease in our study (96.7%) shows that there is a significant difference in etiology between Vietnamese patients and European or American patients. Among 206 adult French patientswith mitral valve insufficiency who were operated on in Broussais Hospital, Paris, France (from 1972 to 1979), 58% had degenerative disease and 38% had rheumatic disease.3 The valvular lesions in rheumatic disease are very complex and difficult to repair. A typical lesion is severe restricted motion of the posterior leaflet associated with some degree of anterior leaflet prolapse.1,3 Almost all of our patients had annulus dilatation and required prosthetic rings. A prosthetic ring has 3 functions: it restores the size of the dilated annulus to normal; if the annulus is deformed, it reinstates the normal shape; and it prevents further dilatation of the annulus.2,5
In rheumatic valvular disease, particularly in children, the leaflets are sometimes retracted due to a lack of valvular tissue. In such patients, it was difficult to use a large size of prosthetic ring because the anterior leaflet surface was small (the size of the ring was selected according to the size of the anterior leaflet).1–3,5,6 In these cases, valve extension with glutaraldehyde-preserved autologous pericardium was very useful. The pericardial patch was trimmed to remove fat and pleural tissue and then placed in a 0.65% glutaraldehyde-buffer solution at room temperature for 10 minutes. After this period of fixation, the patch was rinsed in normal saline for 15 minutes in three different baths.4,6,7 If the anteroposterior diameter was insufficient, an ovoid transverse patch was used. When the transverse diameter was insufficient, an ovoid vertical patch was employed. With this technique, a larger ring could be used than would have been possible without extension.
Intraoperative transesophageal echocardiography allowed assessment of the results of valvuloplasty from the moment when cardiac activity restarted under extracorporeal circulation, until complete rewarming of the patient and weaning from the bypass.4,8
Anticoagulant treatment is recommended for all patients after valve repair.1 In patients who have sinus rhythm postoperatively, anticoagulation should be maintained for 3 months. In the remaining patients, electrical cardioersion should be attempted 1 to 3 months after the operation. If sinus rhythm is established, anticoagulants should be continued for 3 more months. In patients with irreversible atrial fibrillation, anticoagulants are for life.
Patient selection in this series was based on the valvular disease rather than age, physical condition or the cause of valvular disease. More than half (56%) of our patients were in New York Heart Association functional classes I and II. In these patients, the valvular lesions were less complicated and therefore easier to repair. In patients who are in poor condition preoperatively, the long-term results are less favorable. The low mortality and complication rates in this series confirm that mitral valve reconstruction by Carpentier's techniques is appropriate for patients with mitral incompetence and we found it to be particularly suitable for children.
Presented at the 13th Biennial Asian Congress on Thoracic and Cardiovascular Surgery, Sydney, Australia, October 12–15, 1997.
|
REFERENCES
|
|---|
-
Carpentier A. Reconstruction surgery of mitral valve incompetence. J Thorac Cardiovasc Surg
1980;79:338–48.[Abstract]
-
Carpentier A. Cardiac valve surgery — the "French correction". Thorac Cardiovasc Surg
1983;86:323–7.
-
Deloche A, Carpentier A. Valve repair with Carpentier techniques. J Thorac Cardiovasc Surg
1990;99:990–1002.[Abstract]
-
Chauvaud S, Carpentier A. Valve extension with glutaraldehyde-preserved autologous pericardium. J Thorac Cardiovasc Surg
1991;102:171–8.[Abstract]
-
Acar C, Deloche A. Anatomie et physiologie des valves mitral et tricuspide. In: Heart valve diseases and repair. Asia Life Teleconference
, 1994:4–20.
-
Becker AE, De Wit APM. Mitral valve apparatus. A spectrum of normality relevant to mitral valve prolapse. Br Heart J
1979;42:680–9.[Free Full Text]
-
Chauvaud S. Long-term results of valve repair in children with acquired mitral valve incompetence. Circulation
1986;74(Suppl I):I-104–9.
-
Mihaileanu S. Intraoperative transesophageal echocardiography after mitral repair. Specific conditions and pitfalls. Eur Heart J
1991;12(Suppl B):26–9.
This article has been cited by other articles:
|
|
|
|
 
H.-Q. T. Ho, V.-P. Nguyen, K.-P. Phan, and N.-V. Pham
Mitral Valve Repair with Aortic Valve Replacement in Rheumatic Heart Disease
Asian Cardiovasc Thorac Ann,
December 1, 2004;
12(4):
341 - 345.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
A T. Pezzella
Is It Time to Look for an Alternative?
Asian Cardiovasc Thorac Ann,
December 1, 2001;
9(4):
356 - 356.
[Full Text]
[PDF]
|
|
|
TOP
ABSTRACT
INTRODUCTION
