Asian Cardiovasc Thorac Ann 2001;9:10-13
© 2001 Asia Publishing EXchange Pte Ltd
Mitral Valve Repair With Autologous Pericardial Ring
Taweesak Chotivatanapong, MD,
Choosak Kasemsarn, MD,
Vibhan Sungkahapong, MD,
Pradistchai Chaiseri, MD,
Chaiwuth Yosthasurodom, MD,
Sireethorn Cholitkul, MD
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Cardiothoracic Surgical Division Central Chest Hospital Nonthaburi, Thailand
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For reprint information contact: Taweesak Chotivatanapong, MD Tel: 66 2 588 3119 Fax: 66 2 589 9321 email: taweesak13{at}hotmail.com Cardiothoracic Surgical Division, Central Chest Hospital, Tivanonth Road, Nonthaburi 11000, Thailand.
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Abstract
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Between October 1997 and December 1999, 78 patients underwent mitral valve repair using an autologous pericardial ring for posterior annuloplasty. Five patients with congenital heart disease were excluded from the study, and 1 was lost to follow-up. The remaining patients comprised 45 males and 27 females, aged 17 to 74 years (mean, 43.8 years). Follow-up ranged from 3 to 30 months (mean, 17.6 months). Mitral valve repair was required for rheumatic disease (37), degenerative disease (26), infective endocarditis (4), and ischemic heart disease (5). Isolated valve repair was performed in 42 patients, associated operations were aortic valve replacement with autologous pericardium (5), aortic valve replacement (4), aortic valve repair (3), aortic valve replacement with pulmonary autograft (1), tricuspid valve repair (9), and coronary artery bypass (4). The most frequent surgical procedures were posterior annuloplasty, resection of secondary chordae, and suture annuloplasty (average repair procedures per patient was 4.4). There were 2 hospital deaths; one from acute respiratory failure and one from low cardiac output. Three patients needed mitral valve replacement. Use of an autologous pericardial ring is a safe alternative technique for mitral valve annuloplasty but long-term follow-up is mandatory.
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Introduction
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Mitral annuloplasty has an important role in the long-term stability of mitral valve repair. Several techniques have been used with good long-term results. Early experience of mitral valve repair using an autologous pericardial ring for posterior annuloplasty is described.
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Patients and Methods
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Between October 1997 and December 1999, 78 patients underwent mitral valve repair using an autologous pericardial ring for posterior annuloplasty at Central Chest Hospital. Five patients with associated congenital heart diseases were excluded from this study, and one was lost to follow-up. The remaining 72 patients comprised 45 males and 27 females, aged 17 to 74 years (mean, 43.8 years). Follow-up ranged from 3 to 30 months with a mean of 17.6 months. Mitral valve repair was required for rheumatic disease (37), degenerative disease (26), infective endocarditis (4), and ischemic heart disease (5). Preoperative diagnoses are shown in Table 1
. Preoperatively, 35 patients were in New York Heart Association functional class II, 31 were in class III, and 6 were in class IV. All patients underwent preoperative and postoperative echocardiographic evaluations by cardiologists.
A median sternotomy was performed in all cases and cardiopulmonary bypass was instituted with moderate hypothermia (28°C to 30°C) and cold blood cardioplegia, either antegradely or retrogradely, every 25 to 30 minutes. Warm blood terminal reperfusion was given prior to aortic declamping. The mitral valve was accessed by the superior transseptal approach. Abnormal mitral valve findings were mostly attributable to rheumatic disease (thickened leaflets in 39, shortened chordae in 39, chordal fusion in 34). Other pathological findings that caused valve incompetence were prolapse of the posterior mitral leaflet (23) and prolapse of the anterior leaflet (18). Surgical findings and operations are shown in Tables 2 and 3. All patients needed multiple surgical procedures to accomplish valve repair. The average number of surgical procedures per patient was 4.4. These surgical procedures are listed in Table 4. The mean bypass and aortic crossclamp times were 133.2 minutes and 107.4 minutes, respectively.
The technique to create a pericardial ring was started by measuring the valve ring with a Carpentier valve ring sizer (Baxter-Edwards AG, Horw, Switzerland). The length of the posterior aspect of the sizer between the 2 notches was carefully measured. A piece of autologous pericardium, approximately 0.8 cm wide, was cut according to this length, treated with 0.65% glutaraldehyde solution for 10 minutes, and rinsed 3 times with normal saline (0.9% w/v) for 5 minutes. Posterior annuloplasty with this pericardial ring was carried out with 2/0 Ti-Cron (Sherwood Medical, St. Louis, MO, USA) using the interrupted mattress suture technique. Mitral valve competency was tested periodically by flushing normal saline through the mitral valve. Transesophageal echocardiography was used routinely to assess the valve repair during the operation.
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Results
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There were 2 hospital deaths (mortality rate, 2.8%); one was due to acute respiratory failure and the other was from low cardiac output. There were no deaths during the follow-up period. Two patients needed mitral valve replacement at 3 and 8 months postoperatively because of severe residual mitral stenosis in one case and severe residual mitral regurgitation (MR) due to deformation of the mitral annulus in the other. Another patient needed double valve replacement 1 year postoperatively because of progression of rheumatic disease. All of the other surviving patients improved markedly; 55 were in New York Heart Association functional class I and the other 12 were in class II. The degree of MR was also notably improved after the surgery. Of the 57 patients who had significant degrees of MR preoperatively, only 4 were left with a moderate degree of MR. The other surviving patients showed no regurgitation (in 42) or a mild degree (+1) of residual MR (in 8); 3 of these patients needed prosthetic valve replacement, as mentioned above. This was in contrast to the preoperative period where 12 patients had +2 degree, 29 had +3 degree, and 16 had +4 degree MR. Assessment of left ventricular end-diastolic and endsystolic diameters also showed improvement after the operation. The mean end-diastolic diameter decreased from 60.5 to 51.4 cm, and the end-systolic diameter decreased from 40.5 to 36.7 cm. There were no thromboembolic or bleeding complications during the study. No patient required reoperation for valve ring failure. Other complications were wound infection (2), pericardial effusion (2), transient postoperative confusion (1), bleeding (1), and mycotic aneurysm of the axillary artery that was successfully resected and grafted (1). All responded well to appropriate treatments.
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Discussion
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Mitral valve repair has become the preferred operation for patients with mitral valvular heart disease. Several advantages over mitral valve replacement have been confirmed in a number of studies.1–4 Techniques used to correct mitral valve defects must be precise and ensure long-term stability. Several mitral annuloplasty techniques have been developed to improve the stability of valve repair.1,5,6 Use of an autologous pericardial ring for posterior annuloplasty is based on certain factors. First, it is usually the posterior part of the mitral annulus that dilates during the disease process while the anterior aspect is stable. It is rational and attractive to correct only the diseased part, avoiding the risk of damaging the aortic valve that lies close to the anterior part of the mitral annulus. Second, the mitral annulus is a dynamic structure that changes shape and size throughout the cardiac cycle.7 Maintaining this feature is important for good left ventricular function, as clearly shown in a study by David and colleagues.8 Use of an autologous pericardial ring for posterior annuloplasty provides correction of posterior annular dilatation while maintaining the flexibility of the annulus and its important impact on left ventricular function. Good long-term results of mitral valve repair using posterior pericardial annuloplasty were confirmed by Scrofani and colleagues.9
To ensure an excellent result from the use of a pericardial ring, attention must be paid to the endpoint of posterior annuloplasty. An accurate technique is essential to optimize valve coaptation without jeopardizing the mitral valve orifice. Reduction of the posterior annulus must be symmetrical to avoid distortion of the annulus after the repair. To achieve these goals, the length of the posterior aspect of the valve ring sizer, between the commissures, was carefully measured. This is equivalent to the length of the pericardial ring required and can be regarded as the endpoint of the annuloplasty. Symmetrical reduction is achieved by careful placement of sutures along the posterior annulus. We usually start at each commissure, followed by a suture at the midpoint between the commissures. Additional sutures are placed symmetrically on the two halves. In our experience, this ensured symmetrical reduction of the posterior annulus. It is also important to prevent uncontrolled plication of the pericardial ring when tying the sutures. By the simple technique of pulling the commissural and midpoint sutures tightly while tying the knots, uncontrolled plication can usually be prevented.
In this experience, use of a pericardial ring for mitral valve repair was safe, effective, and reproducible. These early results are very encouraging, with low hospital mortality, substantial improvement of functional status, stable valve repair, and no thromboembolic or bleeding complications. Because the valve ring is made from autologous pericardium, it is cheap and readily available in almost all situations where it is needed. It was concluded that use of an autologous pericardial ring for posterior annuloplasty should be considered as an alternative method of annuloplasty in mitral valve repair. However, because the number of patients and duration of follow-up are limited, long-term follow-up is mandatory to assess the safety and durability of the technique.
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References
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Abstract
Introduction
