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Asian Cardiovasc Thorac Ann 1998;6:216-218
© 1998 Asia Publishing EXchange Pte Ltd

CASE STUDY

Mitral Valve Replacement and Preservation of Subvalvular Apparatus Using Cox's Maze Operation

Masafumi Hioki, MD, Yoshio Iedokoro, MD, Shigeki Yamagishi, MD, Yasuo Yamashita, MD, Kouan Orii, MD, Shigeyuki Hirano, MD, Tomomi Hirata, MD, Noriyoshi Kutukata, MD, Sakae Masuda, MD, Takao Hisayoshi, MD, Shigeo Tanaka, MD1

Department of Surgery
1 Department of Surgery II Nippon Medical School Tokyo, Japan
For reprint information contact: Masafumi Hioki, MD Department of Surgery Nippon Medical School Second Hospital 1-396 Kosugimachi, Nakahara-ku Kawasaki City, Kanagawa 211, Japan Tel: 81 44 733 5181 Fax: 81 44 711 8875

   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 CASE REPORT
 DISCUSSION
 REFERENCES
 
A 58-year-old female with mitral stenosis and atrial fibrillation underwent mitral valve replacement. The subvalvular apparatus was successfully preserved by the Cox's maze operation. The postoperative course was uneventful. One year postoperatively, she is doing well and remains in sinus rhythm. The combined operative techniques are discussed.


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
CASE REPORT
 DISCUSSION
 REFERENCES
 
The maze operation performed concomitantly with a mitral valve replacement has become an important technique for patients with medically refractory atrial fibrillation.1 For maintenance of left ventricular function and avoidance of left ventricular rupture after prosthetic valve replacement, it is important to preserve the mitral subvalvular apparatus. We herein report a good operative course and medium-term outcome of this combined operation for valve replacement preserving the mitral subvalvular apparatus by the maze procedure.


   CASE REPORT
TOP
 ABSTRACT
 INTRODUCTION
 CASE REPORT
DISCUSSION
 REFERENCES
 
A 58-year-old female with a previous history of cerebral embolism was admitted to our hospital in New York Heart Association functional class III. She was 153 cm tall and weighed 43 kg with a body surface area of 1.34 m3. Echocardiography and cardiac catheterization revealed severe mitral stenosis and mild pulmonary hypertension with no thrombus in the left atrium. The operation was performed through a median sternotomy. Standard ascending aorta cannulation and distal bicaval venous cannulation were used. Hypothermic (28°C) extracorporeal circulation was carried out and intermittent antegrade cold blood cardioplegia was infused at 30-minute intervals for myocardial protection. Before clamping the aorta, a right atrial incision and excision of the right atrial appendage were performed by Cox's modified maze III procedure.2 Exposure of the mitral valve was obtained by a superior transseptal approach. The anterior leaflet of the mitral valve with fused bilateral commissures was thickened and partially calcified but the posterior leaflet was relatively soft and pliable. Therefore, traditional reconstruction using valvuloplasty was considered to be impossible. Mitral valve replacement preserving the mitral subvalvular apparatus was performed as follows. The thickened and calcified anterior leaflet was divided into five chordal segments. As the subvalvular apparatus was not markedly diseased, all of the native chordal structures were preserved without slicing the chordal segments. Each segment was trimmed into chordal buttons and reattached to the annulus in an anatomic fashion with horizontal pledgetted mattress sutures. The pliable posterior leaflet was retained completely, together with the attached chordae tendineae, and rolled up into the posterior annulus with sutures (Figure lGo). The mitral valve was replaced with a 23-mm St. Jude Medical valve prosthesis (St. Jude Medical, Inc., St. Paul, MN, USA) sutured onto the reconstructed annulus with 2/0 Ethibond (Ethicon, Inc., Somerville, NJ, USA) horizontal mattress sutures.



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  		Figure 1. After detaching the anterior leaflet from the annulus, dividing it into five chordal buttons, and reattaching it to the anterior annulus, the posterior leaflet was rolled into the annulus with horizontal pledgetted mattress sutures. A = the left atrial appendage site excised by the modified maze procedure, B = the incision site of the pulmonary vein isolation, C = the cryoablation areas ({triangleup}) in the left atrium by the modified maze procedure.

 
After completion of the mitral valve replacement with preservation of the subvalvular apparatus, the next stage of the maze procedure was performed. The left atrium was incised starting from the superior incision line and extending circularly so as to isolate the pulmonary veins in the left atrium. Some incisions were replaced with cryoablation as reported previously.1,2 After these incisions, the left atrium was sutured completely, the aortic cross-clamp was released, and the left side of the heart was de-aired. Then the right atrial incisions were closed with a continuous suture. The aortic cross-clamp time was 135 minutes. The patient was weaned from the pump smoothly with a low dose of dopamine (5 µg·kg–1·min–1). She was converted to sinus rhythm immediately after the operation. The postoperative course was uneventful and she was discharged in excellent condition (Figure 2Go). During the follow-up period of 15 months, she was in New York Heart Association functional class I and free from atrial fibrillation. Transthoracic echocardiography showed normal prosthetic function with no left ventricular outflow obstruction (Figure 3Go).




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  		Figure 2. Electrocardiograms recorded (A) preoperatively and (B) postoperatively.

 



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  		Figure 3. Postoperative transthoracic M-mode echocardiograms showing normal prosthetic function and good cardiac function without left ventricular outflow tract obstruction.

 

   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 CASE REPORT
 DISCUSSION
REFERENCES
 
Cox and colleagues described a new operative technique for the surgical treatment of atrial fibrillation (AF) and presented their clinical results.1–3 Many reports using this procedure confirmed the excellent outcome and some also described successful results in combined operations for mitral valvular disease and AF.4,5 Mitral valve repair with preservation of the valve and subvalvular apparatus is believed to maintain the geometry of the left ventricle and preserve ventricular function. Recently, Sintek and colleagues6 described a technique for preserving the subvalvular apparatus in association with surgical treatment of mitral valve disease. Their technique is based on three principles: (1) resection of sufficient tissue to allow implantation of an adequate size of valve, (2) absence of interference with prosthetic valve function by the preserved structures, and (3) avoidance of left ventricular outflow tract obstruction. We considered that the two procedures should be performed concomitantly in this patient with mitral valvular disease and AF. As a result, her cardiac function and quality of life were markedly improved postoperatively. We regard it as very important that the stenotic mitral annulus and leaflets are sliced and resected to be as thin as possible to allow implantation of an adequate size of valve. The valve size in this case was somewhat limited by the stenotic lesions. However, on the basis of body surface area, the valve size was acceptable. There was no problem in relation to cardiac function after the operation.7 We believe that these procedures, although complicated, can be accomplished safely with a satisfactory result.


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 CASE REPORT
 DISCUSSION
 REFERENCES
 

  1. Cox JL. The surgical treatment of atrial fibrillation. J Thorac Cardiovasc Surg 1991;101:584–92.[Abstract]

  2. Cox JL, Jaquiss RDB, Schuessler RB, Boineau JP. Modification of the maze procedure for atrial flutter and atrial fibrillation. II. Surgical technique of maze III procedure. J Thorac Cardiovasc Surg 1995;110:485–95.[Abstract/Free Full Text]

  3. Feinberg MS, Waggoner AD, Kater KM, Cox JL, Lindsay BD, Perez JE. Restoration of atrial function after the maze procedure for patients with atrial fibrillation. Assessment by Doppler echocardiography. Circulation 1994;90(Suppl II):II-285–92.

  4. McCarthy PM, Cosgrove DM, Castle LW, White RD, Klein AL. Combined treatment of mitral regurgitation and atrial fibrillation with valvuloplasty and the maze procedure. Am J Cardiol 1993;71:483–6.[Medline]

  5. Hioki M, Ikeshita M, Iedokoro Y, et al. Successful combined operation for mitral stenosis and atrial fibrillation. Ann Thorac Surg 1993;55:776–8.[Abstract]

  6. Sintek CF, Pfeffer TA, Kochamba GS, Khonsari S. Mitral valve replacement: technique to preserve the subvalvular apparatus. Ann Thorac Surg 1995;59:1027–9.[Abstract/Free Full Text]

  7. Esper E, Ferdinand FD, Aronson S, Karp RB. Prosthetic mitral replacement: late complications after native valve preservation. Ann Thorac Surg 1997;63:541–3.[Abstract/Free Full Text]





This Article
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