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A Simple Nonresectional Technique for Degenerative Mitral Regurgitation With a Very Large Posterior Leaflet: Chordal Foldoplasty
A Simple Nonresectional Technique for Degenerative Mitral Regurgitation With a Very Large Posterior Leaflet: Chordal Foldoplasty Minoru Tabata, MD, MPH, Daisuke Nakatsuka, MD, Hidefumi Nishida, MD, Shuichiro Takanashi, MD, Nobuhiko Hiraiwa, MD, and Yuji Kawano, MD Department of Cardiovascular Surgery, Tokyo Bay Urayasu Ichikawa Medical Center, Chiba; and Department of Cardiovascular Surgery, Sakakibara Heart Institute, Tokyo, Japan
Leaflet resection with sliding valvuloplasty or additional chordal replacement is a standard technique for very large posterior leaflet prolapse. Regular chordal replacement without resection is simpler than those techniques. However, it may not reduce the leaflet height enough to avoid systolic anterior motion. In our technique, two pairs of neochordae are placed on the middle portion of the prolapsing scallop, which fixes the prolapse, reduces the
functional height of the posterior leaflet, and blocks the leaflet tip from moving forward. This simple nonresectional technique can be easily performed with minimally invasive approaches. Postoperative echocardiography shows excellent leaflet motion and deep coaptation.
Accepted for publication Dec 7, 2015.
W
Address correspondence to Dr Tabata, Department of Cardiovascular Surgery, Tokyo Bay Urayasu Ichikawa Medical Center, 3-4-32 Todaijima, Urayasu-shi, Chiba 279-0001, Japan; email: [email protected].
(Ann Thorac Surg 2016;101:e179–81) Ó 2016 by The Society of Thoracic Surgeons
hen we repair very large posterior leaflet prolapse, we need to reduce the posterior leaflet height to avoid systolic anterior motion (SAM). Leaflet resection with sliding valvuloplasty or additional chordal replacement is
Fig 1. (A) Preoperative echocardiographic view showing very large posterior leaflet prolapse. (B) Prolapse of the large and thick P2 scallop. (C) Two pairs of neochordae are placed on the middle portion of the leaflet instead of the leaflet edge. (D) Ring size is determined based on the anterior leaflet size by using our original silicone sizers that fit the limited working space. (E) The distance between neochordae and annulus is approximately 15 mm, and blue circle shows new coaptation zone. (F) A combination of chordal foldoplasty and gap closure successfully repaired prolapse and reduced the leaflet height without leaflet resection. Ó 2016 by The Society of Thoracic Surgeons Published by Elsevier
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2015.12.013
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HOW TO DO IT TABATA ET AL NONRESECTIONAL REPAIR FOR LARGE POSTERIOR LEAFLET
Ann Thorac Surg 2016;101:e179–81
Fig 2. Postoperative echocardiographic images. Upper row: Images in the diastolic phase show excellent leaflet mobility. Lower row: Images in the systolic phase show deep coaptation, no residual mitral regurgitation, and no systolic anterior motion.
commonly used. Regular chordal replacement without leaflet resection is simpler than those resection techniques; however, it does not reduce the leaflet height enough to avoid SAM when the posterior leaflet is very large. We introduce a modified chordal replacement technique without leaflet resection, chordal foldoplasty, for very large posterior leaflet prolapse.
Technique We have used this technique in 8 patients with posterior leaflet prolapse who underwent mitral valve repair between August 2013 and March 2015. The mean age was 56 9 years, and 1 patient was a woman. In all patients, preoperative echocardiography showed severe mitral regurgitation (MR) caused by very large P2 prolapse. Two patients presented with P3 prolapse as well. The average height of the P2 scallop was 29 mm. We applied a totally endoscopic approach in all cases. A right minithoracotomy with a 3- to 5-cm skin incision was made, and a couple of 5-mm incisions were made for a thoracoscopic port and other instruments. No rib spreader was used. Cardiopulmonary bypass was established with peripheral cannulation, the aorta was cross-clamped with
a transthoracic clamp, and cardiac asystole was obtained with antegrade cold crystalloid cardioplegia. The left atrium was incised, and the mitral valve was exposed with a transthoracic atrial retractor. We first placed annular sutures and then assessed the leaflets and subvalvular apparatus. We found a large and thick P2 scallop with ruptured chordae, elongated chordae, or both. The papillary muscles were exposed by use of the Wakka technique, which we previously introduced [1]. An expanded polytetrafluoroethylene neochord was placed on each papillary muscle in a pledgeted mattress fashion, and then those two pairs of neochordae were sutured on the middle portion of the P2 scallop instead of the leaflet edge (Fig 1). The neochordae were directly sutured in a mattress fashion on the atrial side of the leaflet approximately 15 mm away from the annulus (Fig 1). The distance between two pairs of neochordae on the leaflet was 5 to 10 mm, depending on the prolapsing scallop size. The ring size was determined based on the size of anterior leaflet with use of our original silicone sizers (Fig 1). After the annuloplasty ring was seated, the length of neochordae was determined with the tourniquet technique [2]. We temporarily fixed the neochordae with small tourniquets, assessed the leaflet coaptation by injecting saline into the
Ann Thorac Surg 2016;101:e179–81
Fig 3. Concept schema of chordal foldoplasty. Neochordae placed on the body of the posterior leaflet (red line) create a new edge of the leaflet and reduce the functional height of the leaflet. The original tip of the leaflet is naturally folded toward the posterior wall and does not push the anterior leaflet forward.
left ventricle, and adjusted the length of the chordae by sliding the tourniquets until we confirmed adequate coaptation length and position. In two cases, we found the redundant P3 segment without ruptured chordae. We closed the gap between P2 and P3 by suturing the atrial side of the leaflets to adjust redundancy. In one case, we performed simultaneous tricuspid annuloplasty and pulmonary vein isolation using a radiofrequency device. There was no operative death or major adverse event. Postoperative echocardiography showed deep leaflet coaptation with no residual MR and excellent leaflet motion with no SAM (Fig 2). The median echocardiographic follow-up time was 14 months (range, 6 to 24 months). All mitral valves have maintained deep coaptation. There has been no recurrence of MR or SAM.
Comment Our modified chordal replacement is a very simple and reproducible technique that can be performed both in minimally invasive and conventional approaches. No matter how high the posterior leaflet is, the leaflet is remodeled to the appropriate height by putting the neochordae on the middle portion of the leaflet (Fig 3). Two pairs of neochordae put on the prolapsing scallop naturally
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fold the leaflet toward the posterior ventricular wall, create a new coaptation surface, and block the leaflet tip from moving forward (causing SAM). This technique provides deep leaflet coaptation and preserves excellent leaflet motion, which are advantages of nonresectional techniques compared with resectional techniques [3, 4]. We do not fold the leaflet by suturing with this technique because folding sutures reduce leaflet mobility. Our echocardiographic findings show that placing neochordae 15 mm away from the annulus makes the leaflet surface between 10 and 20 mm away from the annulus the coaptation zone. The validity of 15 mm needs to be further evaluated. This technique can be applied to any scallop of the posterior leaflet. We recommend putting more than one pair of neochordae on each scallop to avoid SAM. Two pairs are sufficient for most scallops; however, more than two may be necessary when the prolapsing segment is very wide. Vertical redundancy of the leaflet can be resolved by chordal foldoplasty alone. We add segmental gap closure when the leaflets are horizontally redundant. A combination of chordal foldoplasty and gap closure makes it possible to repair most posterior leaflet lesions without resection unless the lesion is heavily calcified or infected. Another advantage of nonresectional techniques is that they allow surgeons to undo the repaired valve if it is not satisfactory. This technique may not be feasible when the rough zone of the leaflet is thin. However, a large valve requiring height reduction is almost always associated with leaflet thickening [5]. A thin small valve can be repaired with regular chordal replacement. Also, this technique is not a good option for a heavily calcified leaflet because it would not be nicely folded by neochordae. A combination of leaflet resection and chordal foldoplasty is feasible if the posterior leaflet height remains large after leaflet resection, although we excluded those cases from this report. In conclusion, chordal foldoplasty is a simple and reproducible nonresectional repair technique that fixes prolapse and reduces the leaflet height for very large posterior leaflet prolapse. This technique provides deep coaptation, excellent leaflet mobility, and no SAM.
References 1. Tabata M, Hiraiwa N, Kawano Y, Nakatsuka D, Hoshino S. A simple, effective, and inexpensive technique for exposure of papillary muscles in minimally invasive mitral valve repair: Wakka technique. Ann Thorac Surg 2015;100:e59–61. 2. Tabata M, Kasegawa H, Fukui T, Shimizu A, Sato Y, Takanashi S. Long-term outcomes of artificial chordal replacement with tourniquet technique in mitral valve repair: a single-center experience of 700 cases. J Thorac Cardiovasc Surg 2014;148:2033–8. 3. Falk V, Seeburger J, Czesla M, et al. How does the use of polytetrafluoroethylene neochordae for posterior mitral valve prolapse (loop technique) compare with leaflet resection? A prospective randomized trial. J Thorac Cardiovasc Surg 2008;136:1200–6. 4. Ben Zekry S, Lang RM, Sugeng L, et al. Mitral annulus dynamics early after valve repair: preliminary observations of the effect of resectional versus non-resectional approaches. J Am Soc Echocardiogr 2011;24:1233–42. 5. Adams DH, Rosenhek R, Falk V. Degenerative mitral valve regurgitation: best practice revolution. Eur Heart J 2010;31: 1958–66.
Leaflet resection with sliding valvuloplasty or additional chordal replacement is a standard technique for very large posterior leaflet prolapse. Regular chordal replacement without resection is simpler than those techniques. However, it may not reduce the leaflet height enough to avoid systolic anterior motion. In our technique, two pairs of neochordae are placed on the middle portion of the prolapsing scallop, which fixes the prolapse, reduces the
functional height of the posterior leaflet, and blocks the leaflet tip from moving forward. This simple nonresectional technique can be easily performed with minimally invasive approaches. Postoperative echocardiography shows excellent leaflet motion and deep coaptation.
Accepted for publication Dec 7, 2015.
W
Address correspondence to Dr Tabata, Department of Cardiovascular Surgery, Tokyo Bay Urayasu Ichikawa Medical Center, 3-4-32 Todaijima, Urayasu-shi, Chiba 279-0001, Japan; email: [email protected].
(Ann Thorac Surg 2016;101:e179–81) Ó 2016 by The Society of Thoracic Surgeons
hen we repair very large posterior leaflet prolapse, we need to reduce the posterior leaflet height to avoid systolic anterior motion (SAM). Leaflet resection with sliding valvuloplasty or additional chordal replacement is
Fig 1. (A) Preoperative echocardiographic view showing very large posterior leaflet prolapse. (B) Prolapse of the large and thick P2 scallop. (C) Two pairs of neochordae are placed on the middle portion of the leaflet instead of the leaflet edge. (D) Ring size is determined based on the anterior leaflet size by using our original silicone sizers that fit the limited working space. (E) The distance between neochordae and annulus is approximately 15 mm, and blue circle shows new coaptation zone. (F) A combination of chordal foldoplasty and gap closure successfully repaired prolapse and reduced the leaflet height without leaflet resection. Ó 2016 by The Society of Thoracic Surgeons Published by Elsevier
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2015.12.013
e180
HOW TO DO IT TABATA ET AL NONRESECTIONAL REPAIR FOR LARGE POSTERIOR LEAFLET
Ann Thorac Surg 2016;101:e179–81
Fig 2. Postoperative echocardiographic images. Upper row: Images in the diastolic phase show excellent leaflet mobility. Lower row: Images in the systolic phase show deep coaptation, no residual mitral regurgitation, and no systolic anterior motion.
commonly used. Regular chordal replacement without leaflet resection is simpler than those resection techniques; however, it does not reduce the leaflet height enough to avoid SAM when the posterior leaflet is very large. We introduce a modified chordal replacement technique without leaflet resection, chordal foldoplasty, for very large posterior leaflet prolapse.
Technique We have used this technique in 8 patients with posterior leaflet prolapse who underwent mitral valve repair between August 2013 and March 2015. The mean age was 56 9 years, and 1 patient was a woman. In all patients, preoperative echocardiography showed severe mitral regurgitation (MR) caused by very large P2 prolapse. Two patients presented with P3 prolapse as well. The average height of the P2 scallop was 29 mm. We applied a totally endoscopic approach in all cases. A right minithoracotomy with a 3- to 5-cm skin incision was made, and a couple of 5-mm incisions were made for a thoracoscopic port and other instruments. No rib spreader was used. Cardiopulmonary bypass was established with peripheral cannulation, the aorta was cross-clamped with
a transthoracic clamp, and cardiac asystole was obtained with antegrade cold crystalloid cardioplegia. The left atrium was incised, and the mitral valve was exposed with a transthoracic atrial retractor. We first placed annular sutures and then assessed the leaflets and subvalvular apparatus. We found a large and thick P2 scallop with ruptured chordae, elongated chordae, or both. The papillary muscles were exposed by use of the Wakka technique, which we previously introduced [1]. An expanded polytetrafluoroethylene neochord was placed on each papillary muscle in a pledgeted mattress fashion, and then those two pairs of neochordae were sutured on the middle portion of the P2 scallop instead of the leaflet edge (Fig 1). The neochordae were directly sutured in a mattress fashion on the atrial side of the leaflet approximately 15 mm away from the annulus (Fig 1). The distance between two pairs of neochordae on the leaflet was 5 to 10 mm, depending on the prolapsing scallop size. The ring size was determined based on the size of anterior leaflet with use of our original silicone sizers (Fig 1). After the annuloplasty ring was seated, the length of neochordae was determined with the tourniquet technique [2]. We temporarily fixed the neochordae with small tourniquets, assessed the leaflet coaptation by injecting saline into the
Ann Thorac Surg 2016;101:e179–81
Fig 3. Concept schema of chordal foldoplasty. Neochordae placed on the body of the posterior leaflet (red line) create a new edge of the leaflet and reduce the functional height of the leaflet. The original tip of the leaflet is naturally folded toward the posterior wall and does not push the anterior leaflet forward.
left ventricle, and adjusted the length of the chordae by sliding the tourniquets until we confirmed adequate coaptation length and position. In two cases, we found the redundant P3 segment without ruptured chordae. We closed the gap between P2 and P3 by suturing the atrial side of the leaflets to adjust redundancy. In one case, we performed simultaneous tricuspid annuloplasty and pulmonary vein isolation using a radiofrequency device. There was no operative death or major adverse event. Postoperative echocardiography showed deep leaflet coaptation with no residual MR and excellent leaflet motion with no SAM (Fig 2). The median echocardiographic follow-up time was 14 months (range, 6 to 24 months). All mitral valves have maintained deep coaptation. There has been no recurrence of MR or SAM.
Comment Our modified chordal replacement is a very simple and reproducible technique that can be performed both in minimally invasive and conventional approaches. No matter how high the posterior leaflet is, the leaflet is remodeled to the appropriate height by putting the neochordae on the middle portion of the leaflet (Fig 3). Two pairs of neochordae put on the prolapsing scallop naturally
HOW TO DO IT TABATA ET AL NONRESECTIONAL REPAIR FOR LARGE POSTERIOR LEAFLET
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fold the leaflet toward the posterior ventricular wall, create a new coaptation surface, and block the leaflet tip from moving forward (causing SAM). This technique provides deep leaflet coaptation and preserves excellent leaflet motion, which are advantages of nonresectional techniques compared with resectional techniques [3, 4]. We do not fold the leaflet by suturing with this technique because folding sutures reduce leaflet mobility. Our echocardiographic findings show that placing neochordae 15 mm away from the annulus makes the leaflet surface between 10 and 20 mm away from the annulus the coaptation zone. The validity of 15 mm needs to be further evaluated. This technique can be applied to any scallop of the posterior leaflet. We recommend putting more than one pair of neochordae on each scallop to avoid SAM. Two pairs are sufficient for most scallops; however, more than two may be necessary when the prolapsing segment is very wide. Vertical redundancy of the leaflet can be resolved by chordal foldoplasty alone. We add segmental gap closure when the leaflets are horizontally redundant. A combination of chordal foldoplasty and gap closure makes it possible to repair most posterior leaflet lesions without resection unless the lesion is heavily calcified or infected. Another advantage of nonresectional techniques is that they allow surgeons to undo the repaired valve if it is not satisfactory. This technique may not be feasible when the rough zone of the leaflet is thin. However, a large valve requiring height reduction is almost always associated with leaflet thickening [5]. A thin small valve can be repaired with regular chordal replacement. Also, this technique is not a good option for a heavily calcified leaflet because it would not be nicely folded by neochordae. A combination of leaflet resection and chordal foldoplasty is feasible if the posterior leaflet height remains large after leaflet resection, although we excluded those cases from this report. In conclusion, chordal foldoplasty is a simple and reproducible nonresectional repair technique that fixes prolapse and reduces the leaflet height for very large posterior leaflet prolapse. This technique provides deep coaptation, excellent leaflet mobility, and no SAM.
References 1. Tabata M, Hiraiwa N, Kawano Y, Nakatsuka D, Hoshino S. A simple, effective, and inexpensive technique for exposure of papillary muscles in minimally invasive mitral valve repair: Wakka technique. Ann Thorac Surg 2015;100:e59–61. 2. Tabata M, Kasegawa H, Fukui T, Shimizu A, Sato Y, Takanashi S. Long-term outcomes of artificial chordal replacement with tourniquet technique in mitral valve repair: a single-center experience of 700 cases. J Thorac Cardiovasc Surg 2014;148:2033–8. 3. Falk V, Seeburger J, Czesla M, et al. How does the use of polytetrafluoroethylene neochordae for posterior mitral valve prolapse (loop technique) compare with leaflet resection? A prospective randomized trial. J Thorac Cardiovasc Surg 2008;136:1200–6. 4. Ben Zekry S, Lang RM, Sugeng L, et al. Mitral annulus dynamics early after valve repair: preliminary observations of the effect of resectional versus non-resectional approaches. J Am Soc Echocardiogr 2011;24:1233–42. 5. Adams DH, Rosenhek R, Falk V. Degenerative mitral valve regurgitation: best practice revolution. Eur Heart J 2010;31: 1958–66.