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Partial tricuspid valve transfer for repair of mitral insufficiency due to ruptured chordae tendineae
Partial Tricuspid Valve Transfer for Repair of Mitral Insufficiency Due to Ruptured Chordae Tendineae Francisco Gregori, Jr, MD, Celso O. Cordeiro, MD, Ulisses A. Croti, MD, Sergio S. Hayashi, MD, Samuel S. da Silva, MD, and Thelma E. F. Gregori, MD Department of Surgery, State University of Londrina School of Medicine, Londrina, Parana, Brazil
Background. A new technique is suggested for the reconstructive surgical treatment of mitral regurgitation. It involves partial transfer of the tricuspid valve of the patient to the mitral valve, in order to provide chordae to correct anterior leaflet prolapse of the mitral valve, secondary to rupture of the chordae tendineae. Methods. From January 1991 to May 1997, 20 patients with mitral insufficiency due to rupture of the chordae were operated on. The prevailing cause was myxomatous degeneration (70%). Patients were in New York Heart Association functional class III and IV. Results. There were no hospital deaths. Two patients were reoperated on. Eighteen patients (90%) are alive with their own valves (class I and II). Doppler echocar-
diogram mean values were: ejection fraction, 0.65; left atrial diameter, 4.2 cm; mitral area, 2.4 cm2; mitral transvalvular gradient, 3.3 mm Hg. No regurgitation or mild regurgitation was observed in 16 (94.1%) of the 17 cases evaluated. Mean tricuspid valvular area was 3.3 cm2. In all cases, no tricuspid regurgitation was present or it was mild. Conclusions. Partial transfer of the tricuspid valve to the mitral valve is an effective procedure for the surgical treatment of mitral valve insuffiency secondary to ruptured chordae tendineae of the anterior leaflet.
R
anterior leaflet by tailoring artificial chordae of bovine pericardium treated with glutaraldehyde [6] or polytetrafluorethilene [7]. Since January 1991, we have used a technique pioneered by us for repair of the anterior leaflet of the mitral valve prolapse, due to rupture of the chordae tendineae. It involves providing chordae from partial transfer of the tricuspid valve to the mitral valve [8] of the same patient. The objective of this study is to present the postoperative evolution of a consecutive series of patients, bearers of mitral valve insufficiency secondary to rupture of the chordae tendineae, submitted to repair surgery using the technique of partial transfer of the tricuspid valve to the mitral valve.
upture of the chordae, leading to prolapse of the corresponding leaflet was surgically treated at the beginning of cardiopulmonary bypass surgery by McGoon [1], by plicature of the prolapsed portion of the leaflet. Initial results were positive, however, on the long term, ended in a lesser mobility of the leaflet, especially the anterior one. Merendino and coworkers [2], proposed resection of the posterior leaflets of the mitral valve, thus eliminating the prolapse and suturing, edge-to-edge, the remaining posterior leaflets, at the same time performing posterior mitral plicature. This technique is still utilized today [3] with excellent results, however it is restricted to rupture of the posterior leaflet chordae. In 1978, Carpentier and coworkers [4] introduced the technique, used worldwide with positive results, of transferring chordae from the posterior leaflet to the anterior leaflet of the mitral valve in cases of rupture of chordae tendineae. The creation of a new chordae, using a patch of tissue from the anterior leaflet, was proposed by us (1988) for prolapse repair in cases of anterior leaflet chordae rupture [5]. However, it was conditioned to an excess of tissue as found in myxomatous degeneration. In such cases, the surface of the anterior leaflet would not be reduced with consequent restriction of its motility. Valvular prolapse has been treated with other techniques in an effort to avoid movement restriction of the Accepted for publication May 25, 1999. Address reprint requests to Dr Gregori, Rua Paes Leme, 1264 —sala 701, Londrina, Parana, 86010-5203 Brazil; e-mail: [email protected].
© 1999 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
(Ann Thorac Surg 1999;68:1686 –91) © 1999 by The Society of Thoracic Surgeons
Material and Methods A retrospective study of 20 patients submitted to reconstructive repair of the mitral valve from January 1991 to May 1997 was undertaken. Patients presented with mitral valve insufficiency due to rupture of the anterior leaflet chordae tendineae, having been consecutively operated on by the same surgical team, following the technique of partial transfer of the tricuspid valve to the anterior leaflet of the mitral valve for the supply of chordae. Nine patients were male and 11 were female. Ages ranged from 6 to 68 years, mean of 42 years. All patients presented with mitral valve insufficiency; five presented 0003-4975/99/$20.00 PII S0003-4975(99)00850-4
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Fig 1. Removal of the posterior leaflet of the tricuspid valve, rendering it bicuspid. The specimen (lower) containing the leaflet, chordae tendinae, and the papillary muscle will be transferred to the mitral valve.
associated tricuspid insufficiency and four patients presented significant aortic valvular disease. Prevailing etiology was myxomatous degeneration (14 cases) followed by rheumatic (5 cases) and infectious endocarditis (1 case). Five patients were in functional class III and 15 patients in class IV (New York Heart Association). Systolic murmur on the mitral area was found in all patients being mild in 4, significant in 3, and severe in 13. Clinical diagnosis was confirmed by echocardiographic and/or hemodynamic assays. Moderate mitral regurgitation was observed in 4 patients and severe in 16. Three patients presented atrial fibrillation. Perfusion was performed under moderate systemic hypothermia (28 to 32°C). The average time for cardiopulmonary bypass was 93 minutes (minimum, 64; maximum, 135). Average crossclamp time was 49 minutes (minimum, 5; maximum, 106). Supply of chordae for the anterior leaflet of the mitral valve proceeded according to two techniques. The first and more frequent (17 cases) consisted of removal of the posterior leaflet of the tricuspid valve of the patient, with all its elements, that is, with chordae and papillary muscle (Fig 1). This specimen was transferred to the mitral valve by suturing the papillary muscle to that of the mitral valve, corresponding to the ruptured chordae, using two stitches in U anchored on small Dacron pledgets. After attaching the papillary muscle, the donor leaflet was sutured to the anterior leaflet of the mitral valve avoiding too long chordae, that would cause leaflet prolapse and consequent mitral insufficiency. The same care must be taken with regard to the opposite, that is, chordae retraction with unwanted coaptation of the anterior leaflet causing mitral insuffiency (Fig 2). The tricuspid annulus was plicated with 4-0 polypropylene sutures, anchored on Dacron pledgets at the posterior portion, leaving the bicuspid valve, furthermore correcting any eventual functional insufficiency. The second technique (2 cases), a variant of the first, was applied when the posterior leaflet of the tricuspid valve, or even the corresponding papillary muscle, were not anatomically adequate. In these cases, the anterior valve is always more developed, to compensate for the
Fig 2. The intraoperative aspect after suture of the graft on the papillary muscle and the anterior leaflet of the mitral valve.
small posterior leaflet. Thus, a triangular patch (Fig 3) was removed from the anterior leaflet, with a satisfactory number and texture of chordae, and a wedge of the corresponding papillary muscle, which was transferred to the mitral valve and sutured, likewise to the already described technique. The tricuspid valve, in these cases, remained with three leaflets with the sectioned edges of the anterior leaflet being joined with separate 5-0 polypropylene stitches. In one case, the graft was used to repair, at the same time, prolapse of the anterior and posterior leaflets of the mitral valve. The grafted leaflet was sectioned in the middle, remaining with two heads linked to the papillary muscle by a good number of
Fig 3. Removal of the graft from the anterior leaflet of the tricuspid valve with chordae tendineae and part of the papillary muscle.
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chordae. One of these heads was sutured to the anterior leaflet and the other to the posterior one (Fig 4). Enlargement of the mitral annulus, found in all cases, was repaired using the prosthetic Gregori ring [9]. This prosthesis is an industrialized half-ring, commercially available (Braile-Biome´dica, Sa˜o Jose´ do Rio Preto, SP, Brazil). Its shape is similar to that of the Carpentier ring without its anterior stem, and exhibits a modification in its right half. It is only a straightening of the ring’s curve. Thus, the prosthesis has the shape of a half-circle with the right curvature straightened out. The material used is stainless steel 316, coated by a layer of silicon rubber, and finally by Dacron velvet. Shortening of the prolonged chordae was performed in 5 patients according to the techniques described by Carpentier and associates [10], and by us [11]. In 5 patients, we performed resections of the posterior leaflet (Merendino and coworkers) [2]. Of the 5 patients with functional insufficiency of the tricuspid valve, 1 was submitted to the DeVega annuloplasty [12] (graft removed from the anterior leaflet). In the other 4 patients, tricuspid insufficiency was corrected at the time of annulus plicature, after removal of the posterior valve to be transferred. One patient was submitted to Cox–Maze surgery without use of cryoablation [13], for simultaneous treatment of atrial fibrillation. Four patients underwent aortic valve surgery, with replacement by bovine pericardium bioprostheses in 3 and by aortic valvuloplasty in 1.
Postoperative Evaluation Hospital and late mortality, as well as reoperations, were observed as a result of failure of the repair surgery, in addition to postoperative morbidity. Patients were clinically evaluated, with a mean postoperative follow-up of 4 years and 2 months (ranging from 11 months to 7 years and 4 months). Overall cardiac size was evaluated by roentgenogram for assessment of the cardiothoracic index. Patients were submitted to Doppler echocardiogram to assess the left ventricular function, left atrium diameter, area of the mitral valve orifice, mean transvalvular gradient, and degree of valvular regurgitation. Furthermore, the tricuspid valve was evaluated measuring the valvular
Fig 4. The graft providing chordae to the anterior and posterior leaflets of the mitral valve. With this technique, rectangular resection of the prolapse of the posterior leaflet is avoided.
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Fig 5. Intraoperative picture of the anterior leaflet of the mitral valve, removed after recurrence of mitral insufficiency of a patient presenting with infectious endocarditis at the fourth postoperative month. Arrows show the preserved anatomical structures next to the sutures.
area, transvalvular gradient, and quantifying the degree of valvular regurgitation.
Statistical Analysis Actuarial curves of patient survival and of event-free patients related to the surgical procedure were performed [14].
Results There were no hospital deaths. No thromboembolic events nor hemolysis were observed in the late postoperative period. Two patients presented atrial fibrillation, thus reversing to sinus rhythm in only 1 patient who had been submitted to Cox–Maze surgery. Two female patients (10%) were reoperated because they presented with recurrence of mitral valvular insufficiency. One of them had infectious endocarditis in the 4th postoperative month, requiring valve replacement by a porcine bioprosthesis. Intraoperative evaluation of the mitral valve disclosed that the graft was anatomically protected (Fig 5), while the infection had impaired the contralateral commissure of the mitral valve including rupture of the chordae. The patient died in the immediate postoperative period in low cardiac output. Another female patient was reoperated, 16 months after the first surgery, secondary to mitral insufficiency provoked by dehiscence of the prosthetic ring. During surgery, we observed excellent performance of the graft and only the prosthetic ring was replaced, with a favorable evolution of the patient. One patient died 2 years postoperatively by ventricular fibrillation, that was documented by Holter for assessment of the cardiac rhythm, as the patient had already
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Fig 6. Actuarial survival curve.
been submitted to reconstructive surgery of the mitral valve associated to Cox–Maze surgery. The patient in functional class I was evaluated by Doppler echocardiogram 1 week before death, which disclosed excellent performance of the mitral and tricuspid valves. Eighteen patients (90%) are alive with their own mitral and tricuspid valves; 16 patients are in functional class I, and 2 patients (10%) in functional class II. Mitral valve auscultation was satisfactory in all patients; murmur was absent in 6 (30%), mild systolic murmur was found in 11 (55%), and moderate in 1 patient (5%). No patients presented systolic murmur at the tricuspid area. One patient who was simultaneously submitted to aortic valvuloplasty progressed with a significant diastolic murmur in the aortic area, due to residual aortic insufficiency. Eleven patients (55%) use Digoxin daily, 3 of them associated to Furosemide; 1 takes only Furosemide. Evaluation of the cardiac area showed that patients had a mean cardiothoracic index of 0.50, with a minimum of 0.42 and a maximum of 0.58. The actuarial survival curve of the patients showed, at 8 years, a survival probability of 89.1 ⫾ 7.3% (Fig 6). Postoperative evaluation by Doppler echocardiogram was performed in 17 of the 18 surviving patients. One patient, who had no symptoms without any medication, refused to undergo laboratory examinations. Left ventricular function, measured by ejection fraction showed a mean value of 0.65 (ranging from 0.39 to 0.80). The mean diameter of the left atrium was 4.2 cm, with a minimum of 3.3 cm and a maximum of 5.7 cm. The mean mitral valvular area was 2.4 cm2 (minimum, 1.7 cm2; maximum, 3.6 cm2). The average of the mean mitral valvular gradient was 3.3 mm Hg (from 0 to 13 mm Hg). Absence of mitral valvular regurgitation was observed in 9 patients (45%), mild regurgitation in 7 (35%), and moderate regurgitation in 1 (5%). Therefore, satisfactory competence of the mitral valve was observed in 16 (94.1%) of the 17 evaluated patients. The average area of the tricuspid valve was 3.3 cm2 (minimum, 2.2; maximum, 4.4). No transvalvular tricuspid gradients were
recorded. Three patients (15%) presented mild tricuspid regurgitation, which was not found in the remaining group. The actuarial curve of patients with no complications, showed that, after 8 years, 93.8 ⫾ 6.1% were free of events (Fig 7).
Comments Management of valvular prolapses due to rupture of the chordae is an easier procedure when found in the posterior leaflet. When faced with rupture of the chordae tendineae, surgeons take distinctive actions if it is found in the anterior leaflet of the mitral valve. We believe that the supply of chordae tendineae extracted from the tricuspid valve of the patient, is an excellent choice, as the basic structure of the mitral valve remains unchanged and the bicuspidization technique of the tricuspid valve is far from causing stenosis, much to the contrary, in almost one third of the cases, it corrects the existing functional valvular insufficiency. Maybe, suture of the papillary muscles presents the greatest difficulty. Currently, we place the graft with a 5-0 polypropylene U-shaped stitch already set on a Dacron pledget, which shall be sutured to the papillary muscle of the mitral valve with ruptured chordae, being, at this level, the only suture. This procedure facilitates the assessment of the extension of the chordae with regard to joining of the donating leaflet to the anterior leaflet of the mitral valve. Regarding the shorter chordae, we leave more leaflet and we proceed conversely when those are long. Therefore, the technique, for a surgical team experienced in valvular repair, is perfectly reproducible. A similar procedure was further described by Hvass and coworkers [15] in 1995. Sutures are stable because papillary muscles rapidly undergo fibrosis at the suture site, further reinforcing the junction. In the 2 reoperated patients, the observed anatomic condition was quite favorable, so much so that one of them, whose prosthetic ring became dehiscent postoperatively, continues with the graft in perfect func-
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Fig 7. Actuarial event-free survival curve.
tioning. In no case did we observe rupture of the sutures bringing about significant mitral regurgitation. Combined, a variety of techniques were utilized. In all cases, two were always combined: annuloplasty with open ring for correction of the mitral annulus dilatation and partial transfer of the posterior leaflet for provision of chordae tendineae to the mitral valve. Unquestionably, no valve would be efficient with ruptured chordae and, therefore, any associated technique, including annuloplasty, would not, by itself, solve prolapse of the anterior leaflet caused by rupture of the chordae. Thus, the positive late outcome is a contingent technique and the analysis, albeit not retrospective and not randomized, is further validated because it is a consecutive series, and the surgical team and the institution are the same. Absence of hospital death in the series corroborates the low mortality rates found in literature for mitral valve repair surgeries [16, 17]. Clinical evolution was excellent with 90% of the patients alive with their own valves at functional class I and II and with reasonable cardiac auscultation, in addition to the fact that no thromboembolitic or hemolytic phenomena occurred. As an auxiliary fact, we could observe, at radiological analysis of the thorax, the confirmation of the excellent clinical condition of the patients, as the average of the cardiothoracic index values evolved within the ranges of normality. Positive Doppler echocardiographic evolution confirmed data of clinical observation. Left ventricular function was maintained, and we also could observe the dimensions of the left atrium and of the mitral and tricuspid valvular area rather satisfactorily, with low transvalvular gradients. Furthermore, functionality of the mitral valve was satisfactory in over 90% of the cases, with no damage to the tricuspid valve. The positive evolution of the patients, as well as the effectiveness of the utilized surgical procedure, may be observed in the analysis of the actuarial curves at 8 years, with about 90% probability of the patients being alive and free from complications.
To conclude, partial transfer of the tricuspid valve to the mitral valve associated to other techniques of valvular repair, is an efficient and safe procedure for the surgical treatment of mitral insufficiency secondary to rupture of chordae of the anterior leaflet.
References 1. McGoon DC. Repair of mitral insufficiency due to ruptured chordae tendineae. J Thorac Cardiovasc Surg 1960; 39:357– 62. 2. Merendino KA, Thomas GI, Jesseph JE, Herron PW, Winterscheid LC, Vetto RR. The open correction of rheumatic mitral regurgitation treated by posterior medial annuloplasty utilizing a pump oxygenator. Ann Surg 1959; 150:5–22. 3. Pomerantzeff PMA, Branda˜o CMA, Roni EG, et al. Quadrangular ressection without ring annuloplasty in mitral valve repair. Eur Cardiovasc Surg 1997;2:271–3. 4. Carpentier A, Relland J, Deloche A, et al. Conservative management of the prolapsed mitral valve. Ann Thorac Surg 1978;26:294 –302. 5. Gregori F Jr, Takeda R, Silva SS, Fac¸anha L, Meier MA. A new technique for mitral insufficiency caused by ruptured chordae of the anterior leaflet. J Thorac Cardiovasc Surg 1988;96:765– 8. 6. Frater RWM, Gabray S, Shore D, Factor S, Strom J. Reproducible replacement of elongated or ruptured mitral valve chordae. Ann Thorac Surg 1983;35:14–27. 7. David TE, Boss J, Rakowski H. Mitral valve repair by replacement of chordae tendineae with polytetrafluorethilene sutures. J Thorac Cardiovasc Surg 1991;101:495–501. 8. Gregori F Jr, Silva SS, Goulart MLP, Canesin O, Hayashi SS. Grafting of chordae tendineae: a new technique for the repair of mitral insufficiency caused by ruptured chordae of the anterior leaflet [Letter]. J Thorac Cardiovasc Surg 1994; 107:635–7. 9. Gregori F Jr, Silva SS, Hayashi SS, Aquino WK, Cordeiro CO, Silva LR. Mitral valvuloplasty with a new prosthetic ring. Analysis of the first 105 cases. Eur J Cardiothorac Surg 1994;8:168–72. 10. Carpentier A, Deloche A, Dauptain J, et al. A new reconstructive operation for correction of mitral and tricuspid insufficiency. J Thorac Cardiovasc Surg 1971;61:1–13. 11. Gregori F Jr, Takeda R, Fac¸anha LA, et al. A new reconstructive technique for mitral insufficiency secondary to elon-
Background. A new technique is suggested for the reconstructive surgical treatment of mitral regurgitation. It involves partial transfer of the tricuspid valve of the patient to the mitral valve, in order to provide chordae to correct anterior leaflet prolapse of the mitral valve, secondary to rupture of the chordae tendineae. Methods. From January 1991 to May 1997, 20 patients with mitral insufficiency due to rupture of the chordae were operated on. The prevailing cause was myxomatous degeneration (70%). Patients were in New York Heart Association functional class III and IV. Results. There were no hospital deaths. Two patients were reoperated on. Eighteen patients (90%) are alive with their own valves (class I and II). Doppler echocar-
diogram mean values were: ejection fraction, 0.65; left atrial diameter, 4.2 cm; mitral area, 2.4 cm2; mitral transvalvular gradient, 3.3 mm Hg. No regurgitation or mild regurgitation was observed in 16 (94.1%) of the 17 cases evaluated. Mean tricuspid valvular area was 3.3 cm2. In all cases, no tricuspid regurgitation was present or it was mild. Conclusions. Partial transfer of the tricuspid valve to the mitral valve is an effective procedure for the surgical treatment of mitral valve insuffiency secondary to ruptured chordae tendineae of the anterior leaflet.
R
anterior leaflet by tailoring artificial chordae of bovine pericardium treated with glutaraldehyde [6] or polytetrafluorethilene [7]. Since January 1991, we have used a technique pioneered by us for repair of the anterior leaflet of the mitral valve prolapse, due to rupture of the chordae tendineae. It involves providing chordae from partial transfer of the tricuspid valve to the mitral valve [8] of the same patient. The objective of this study is to present the postoperative evolution of a consecutive series of patients, bearers of mitral valve insufficiency secondary to rupture of the chordae tendineae, submitted to repair surgery using the technique of partial transfer of the tricuspid valve to the mitral valve.
upture of the chordae, leading to prolapse of the corresponding leaflet was surgically treated at the beginning of cardiopulmonary bypass surgery by McGoon [1], by plicature of the prolapsed portion of the leaflet. Initial results were positive, however, on the long term, ended in a lesser mobility of the leaflet, especially the anterior one. Merendino and coworkers [2], proposed resection of the posterior leaflets of the mitral valve, thus eliminating the prolapse and suturing, edge-to-edge, the remaining posterior leaflets, at the same time performing posterior mitral plicature. This technique is still utilized today [3] with excellent results, however it is restricted to rupture of the posterior leaflet chordae. In 1978, Carpentier and coworkers [4] introduced the technique, used worldwide with positive results, of transferring chordae from the posterior leaflet to the anterior leaflet of the mitral valve in cases of rupture of chordae tendineae. The creation of a new chordae, using a patch of tissue from the anterior leaflet, was proposed by us (1988) for prolapse repair in cases of anterior leaflet chordae rupture [5]. However, it was conditioned to an excess of tissue as found in myxomatous degeneration. In such cases, the surface of the anterior leaflet would not be reduced with consequent restriction of its motility. Valvular prolapse has been treated with other techniques in an effort to avoid movement restriction of the Accepted for publication May 25, 1999. Address reprint requests to Dr Gregori, Rua Paes Leme, 1264 —sala 701, Londrina, Parana, 86010-5203 Brazil; e-mail: [email protected].
© 1999 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
(Ann Thorac Surg 1999;68:1686 –91) © 1999 by The Society of Thoracic Surgeons
Material and Methods A retrospective study of 20 patients submitted to reconstructive repair of the mitral valve from January 1991 to May 1997 was undertaken. Patients presented with mitral valve insufficiency due to rupture of the anterior leaflet chordae tendineae, having been consecutively operated on by the same surgical team, following the technique of partial transfer of the tricuspid valve to the anterior leaflet of the mitral valve for the supply of chordae. Nine patients were male and 11 were female. Ages ranged from 6 to 68 years, mean of 42 years. All patients presented with mitral valve insufficiency; five presented 0003-4975/99/$20.00 PII S0003-4975(99)00850-4
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Fig 1. Removal of the posterior leaflet of the tricuspid valve, rendering it bicuspid. The specimen (lower) containing the leaflet, chordae tendinae, and the papillary muscle will be transferred to the mitral valve.
associated tricuspid insufficiency and four patients presented significant aortic valvular disease. Prevailing etiology was myxomatous degeneration (14 cases) followed by rheumatic (5 cases) and infectious endocarditis (1 case). Five patients were in functional class III and 15 patients in class IV (New York Heart Association). Systolic murmur on the mitral area was found in all patients being mild in 4, significant in 3, and severe in 13. Clinical diagnosis was confirmed by echocardiographic and/or hemodynamic assays. Moderate mitral regurgitation was observed in 4 patients and severe in 16. Three patients presented atrial fibrillation. Perfusion was performed under moderate systemic hypothermia (28 to 32°C). The average time for cardiopulmonary bypass was 93 minutes (minimum, 64; maximum, 135). Average crossclamp time was 49 minutes (minimum, 5; maximum, 106). Supply of chordae for the anterior leaflet of the mitral valve proceeded according to two techniques. The first and more frequent (17 cases) consisted of removal of the posterior leaflet of the tricuspid valve of the patient, with all its elements, that is, with chordae and papillary muscle (Fig 1). This specimen was transferred to the mitral valve by suturing the papillary muscle to that of the mitral valve, corresponding to the ruptured chordae, using two stitches in U anchored on small Dacron pledgets. After attaching the papillary muscle, the donor leaflet was sutured to the anterior leaflet of the mitral valve avoiding too long chordae, that would cause leaflet prolapse and consequent mitral insufficiency. The same care must be taken with regard to the opposite, that is, chordae retraction with unwanted coaptation of the anterior leaflet causing mitral insuffiency (Fig 2). The tricuspid annulus was plicated with 4-0 polypropylene sutures, anchored on Dacron pledgets at the posterior portion, leaving the bicuspid valve, furthermore correcting any eventual functional insufficiency. The second technique (2 cases), a variant of the first, was applied when the posterior leaflet of the tricuspid valve, or even the corresponding papillary muscle, were not anatomically adequate. In these cases, the anterior valve is always more developed, to compensate for the
Fig 2. The intraoperative aspect after suture of the graft on the papillary muscle and the anterior leaflet of the mitral valve.
small posterior leaflet. Thus, a triangular patch (Fig 3) was removed from the anterior leaflet, with a satisfactory number and texture of chordae, and a wedge of the corresponding papillary muscle, which was transferred to the mitral valve and sutured, likewise to the already described technique. The tricuspid valve, in these cases, remained with three leaflets with the sectioned edges of the anterior leaflet being joined with separate 5-0 polypropylene stitches. In one case, the graft was used to repair, at the same time, prolapse of the anterior and posterior leaflets of the mitral valve. The grafted leaflet was sectioned in the middle, remaining with two heads linked to the papillary muscle by a good number of
Fig 3. Removal of the graft from the anterior leaflet of the tricuspid valve with chordae tendineae and part of the papillary muscle.
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chordae. One of these heads was sutured to the anterior leaflet and the other to the posterior one (Fig 4). Enlargement of the mitral annulus, found in all cases, was repaired using the prosthetic Gregori ring [9]. This prosthesis is an industrialized half-ring, commercially available (Braile-Biome´dica, Sa˜o Jose´ do Rio Preto, SP, Brazil). Its shape is similar to that of the Carpentier ring without its anterior stem, and exhibits a modification in its right half. It is only a straightening of the ring’s curve. Thus, the prosthesis has the shape of a half-circle with the right curvature straightened out. The material used is stainless steel 316, coated by a layer of silicon rubber, and finally by Dacron velvet. Shortening of the prolonged chordae was performed in 5 patients according to the techniques described by Carpentier and associates [10], and by us [11]. In 5 patients, we performed resections of the posterior leaflet (Merendino and coworkers) [2]. Of the 5 patients with functional insufficiency of the tricuspid valve, 1 was submitted to the DeVega annuloplasty [12] (graft removed from the anterior leaflet). In the other 4 patients, tricuspid insufficiency was corrected at the time of annulus plicature, after removal of the posterior valve to be transferred. One patient was submitted to Cox–Maze surgery without use of cryoablation [13], for simultaneous treatment of atrial fibrillation. Four patients underwent aortic valve surgery, with replacement by bovine pericardium bioprostheses in 3 and by aortic valvuloplasty in 1.
Postoperative Evaluation Hospital and late mortality, as well as reoperations, were observed as a result of failure of the repair surgery, in addition to postoperative morbidity. Patients were clinically evaluated, with a mean postoperative follow-up of 4 years and 2 months (ranging from 11 months to 7 years and 4 months). Overall cardiac size was evaluated by roentgenogram for assessment of the cardiothoracic index. Patients were submitted to Doppler echocardiogram to assess the left ventricular function, left atrium diameter, area of the mitral valve orifice, mean transvalvular gradient, and degree of valvular regurgitation. Furthermore, the tricuspid valve was evaluated measuring the valvular
Fig 4. The graft providing chordae to the anterior and posterior leaflets of the mitral valve. With this technique, rectangular resection of the prolapse of the posterior leaflet is avoided.
Ann Thorac Surg 1999;68:1686 –91
Fig 5. Intraoperative picture of the anterior leaflet of the mitral valve, removed after recurrence of mitral insufficiency of a patient presenting with infectious endocarditis at the fourth postoperative month. Arrows show the preserved anatomical structures next to the sutures.
area, transvalvular gradient, and quantifying the degree of valvular regurgitation.
Statistical Analysis Actuarial curves of patient survival and of event-free patients related to the surgical procedure were performed [14].
Results There were no hospital deaths. No thromboembolic events nor hemolysis were observed in the late postoperative period. Two patients presented atrial fibrillation, thus reversing to sinus rhythm in only 1 patient who had been submitted to Cox–Maze surgery. Two female patients (10%) were reoperated because they presented with recurrence of mitral valvular insufficiency. One of them had infectious endocarditis in the 4th postoperative month, requiring valve replacement by a porcine bioprosthesis. Intraoperative evaluation of the mitral valve disclosed that the graft was anatomically protected (Fig 5), while the infection had impaired the contralateral commissure of the mitral valve including rupture of the chordae. The patient died in the immediate postoperative period in low cardiac output. Another female patient was reoperated, 16 months after the first surgery, secondary to mitral insufficiency provoked by dehiscence of the prosthetic ring. During surgery, we observed excellent performance of the graft and only the prosthetic ring was replaced, with a favorable evolution of the patient. One patient died 2 years postoperatively by ventricular fibrillation, that was documented by Holter for assessment of the cardiac rhythm, as the patient had already
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Fig 6. Actuarial survival curve.
been submitted to reconstructive surgery of the mitral valve associated to Cox–Maze surgery. The patient in functional class I was evaluated by Doppler echocardiogram 1 week before death, which disclosed excellent performance of the mitral and tricuspid valves. Eighteen patients (90%) are alive with their own mitral and tricuspid valves; 16 patients are in functional class I, and 2 patients (10%) in functional class II. Mitral valve auscultation was satisfactory in all patients; murmur was absent in 6 (30%), mild systolic murmur was found in 11 (55%), and moderate in 1 patient (5%). No patients presented systolic murmur at the tricuspid area. One patient who was simultaneously submitted to aortic valvuloplasty progressed with a significant diastolic murmur in the aortic area, due to residual aortic insufficiency. Eleven patients (55%) use Digoxin daily, 3 of them associated to Furosemide; 1 takes only Furosemide. Evaluation of the cardiac area showed that patients had a mean cardiothoracic index of 0.50, with a minimum of 0.42 and a maximum of 0.58. The actuarial survival curve of the patients showed, at 8 years, a survival probability of 89.1 ⫾ 7.3% (Fig 6). Postoperative evaluation by Doppler echocardiogram was performed in 17 of the 18 surviving patients. One patient, who had no symptoms without any medication, refused to undergo laboratory examinations. Left ventricular function, measured by ejection fraction showed a mean value of 0.65 (ranging from 0.39 to 0.80). The mean diameter of the left atrium was 4.2 cm, with a minimum of 3.3 cm and a maximum of 5.7 cm. The mean mitral valvular area was 2.4 cm2 (minimum, 1.7 cm2; maximum, 3.6 cm2). The average of the mean mitral valvular gradient was 3.3 mm Hg (from 0 to 13 mm Hg). Absence of mitral valvular regurgitation was observed in 9 patients (45%), mild regurgitation in 7 (35%), and moderate regurgitation in 1 (5%). Therefore, satisfactory competence of the mitral valve was observed in 16 (94.1%) of the 17 evaluated patients. The average area of the tricuspid valve was 3.3 cm2 (minimum, 2.2; maximum, 4.4). No transvalvular tricuspid gradients were
recorded. Three patients (15%) presented mild tricuspid regurgitation, which was not found in the remaining group. The actuarial curve of patients with no complications, showed that, after 8 years, 93.8 ⫾ 6.1% were free of events (Fig 7).
Comments Management of valvular prolapses due to rupture of the chordae is an easier procedure when found in the posterior leaflet. When faced with rupture of the chordae tendineae, surgeons take distinctive actions if it is found in the anterior leaflet of the mitral valve. We believe that the supply of chordae tendineae extracted from the tricuspid valve of the patient, is an excellent choice, as the basic structure of the mitral valve remains unchanged and the bicuspidization technique of the tricuspid valve is far from causing stenosis, much to the contrary, in almost one third of the cases, it corrects the existing functional valvular insufficiency. Maybe, suture of the papillary muscles presents the greatest difficulty. Currently, we place the graft with a 5-0 polypropylene U-shaped stitch already set on a Dacron pledget, which shall be sutured to the papillary muscle of the mitral valve with ruptured chordae, being, at this level, the only suture. This procedure facilitates the assessment of the extension of the chordae with regard to joining of the donating leaflet to the anterior leaflet of the mitral valve. Regarding the shorter chordae, we leave more leaflet and we proceed conversely when those are long. Therefore, the technique, for a surgical team experienced in valvular repair, is perfectly reproducible. A similar procedure was further described by Hvass and coworkers [15] in 1995. Sutures are stable because papillary muscles rapidly undergo fibrosis at the suture site, further reinforcing the junction. In the 2 reoperated patients, the observed anatomic condition was quite favorable, so much so that one of them, whose prosthetic ring became dehiscent postoperatively, continues with the graft in perfect func-
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GREGORI ET AL MITRAL VALVULOPLASTY TRICUSPID GRAFT
Ann Thorac Surg 1999;68:1686 –91
Fig 7. Actuarial event-free survival curve.
tioning. In no case did we observe rupture of the sutures bringing about significant mitral regurgitation. Combined, a variety of techniques were utilized. In all cases, two were always combined: annuloplasty with open ring for correction of the mitral annulus dilatation and partial transfer of the posterior leaflet for provision of chordae tendineae to the mitral valve. Unquestionably, no valve would be efficient with ruptured chordae and, therefore, any associated technique, including annuloplasty, would not, by itself, solve prolapse of the anterior leaflet caused by rupture of the chordae. Thus, the positive late outcome is a contingent technique and the analysis, albeit not retrospective and not randomized, is further validated because it is a consecutive series, and the surgical team and the institution are the same. Absence of hospital death in the series corroborates the low mortality rates found in literature for mitral valve repair surgeries [16, 17]. Clinical evolution was excellent with 90% of the patients alive with their own valves at functional class I and II and with reasonable cardiac auscultation, in addition to the fact that no thromboembolitic or hemolytic phenomena occurred. As an auxiliary fact, we could observe, at radiological analysis of the thorax, the confirmation of the excellent clinical condition of the patients, as the average of the cardiothoracic index values evolved within the ranges of normality. Positive Doppler echocardiographic evolution confirmed data of clinical observation. Left ventricular function was maintained, and we also could observe the dimensions of the left atrium and of the mitral and tricuspid valvular area rather satisfactorily, with low transvalvular gradients. Furthermore, functionality of the mitral valve was satisfactory in over 90% of the cases, with no damage to the tricuspid valve. The positive evolution of the patients, as well as the effectiveness of the utilized surgical procedure, may be observed in the analysis of the actuarial curves at 8 years, with about 90% probability of the patients being alive and free from complications.
To conclude, partial transfer of the tricuspid valve to the mitral valve associated to other techniques of valvular repair, is an efficient and safe procedure for the surgical treatment of mitral insufficiency secondary to rupture of chordae of the anterior leaflet.
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