ANNULOPLASTIC PROCEDURES FOR MITRAL INSUFFICIENCY: LATE RESULTS

ANNULOPLASTIC PROCEDURES FOR MITRAL INSUFFICIENCY:

LATE

RESULTS

Viking Olov Björk, M.D., and Elis Malers, M.D., Uppsala,

Sweden

A

NEW surgical procedure must be evaluated by the long-term results. The aim of this paper is to report the valvular function of the mitral orifice up to 3 years after annuloplastic procedures. MATERIAL

Twenty-six patients were operated upon. The youngest was 6 years of age and the oldest 53 years; the average age was 32. Twenty patients were female, 6 were male. Mitral insufficiency was significant in all cases and had been evaluated also by left ventricular angiography before the operation. The contrast medium injected into the left ventricle had completely outlined the left atrium before it passed the middle of the ascending aorta (Groups I and II) in half of the cases (13). In 12 cases the left atrium was outlined when the contrast medium had reached the arch of the aorta (Group I I I ) . I n only one case did the contrast medium reach the middle of the descending aorta (Group IV) when the left atrium was outlined. There was pure mitral insufficiency with a dilated annulus in 16 cases. In 2 of these, a ruptured chordae tendineae was also encountered. Complete ab­ sence of the lateral third of the posterior cusp was found once, and two separate clefts in the anterior leaflet was encountered in one of these cases. One patient had a cleft mitral valve, overlooked at an early operation for a septum primum defect, as well as two perforations at the base of the anterior leaflet. In 9 cases, the mitral insufficiency was combined with mitral stenosis. Aortic insufficiency was also found in 9 cases, of a moderate to severe degree in 3 cases, and necessitated aortic occlusion during the operation in all 9 patients. In one case, a slight tricuspid stenosis and, in another, severe tricuspid insufficiency were encountered as well as the mitral insufficiency. METHODS

A. Perfusion.—Deep hypothermia was used in 2 cases but then abandoned as the valvular function could not be tested on the open, beating heart. PerFrom the Departments of Thoracic Surgery (Head: V. O. Björk, M.D.), and Internal Medicine (Head: B. Ask-Upmark, M.D.), University Hospital, Uppsala, Sweden. Supported by grants from the Swedish National Association Against Heart and Chest Diseases. Received for publication Oct. 16, 1963. 251

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Cardiovas. Surg.

Fig. 1.—A, Diagram of how the sutures are placed in mitral valve plication for a rup­ tured chordae tendineae. This will narrow the distance between the intact chordae. B, When the sutures are tied, the mitral leaflet will not prolapse up in the atrium. This procedure is combined with annuloplasty, as the anterior mitral leaflet is thereby shortened and may not reach the mural leaflet.

fusion at a flow of 2.2 liters per minute per square meter of body surface and at an esophageal temperature of between 30° to 33° C. was carried out in the remaining cases. The average perfusion time was 53 minutes (range 21 to 114) with aortic occlusion in 11 cases of 25 minutes (range 13 to 43). In 9 cases the aorta was never occluded and in 4 cases the aorta was occluded from 2 to 6 min­ utes to prevent air embolism during closure or testing of the valvular function. B. Surgical Technique.—Direct suture of the valve edges was used for the separate clefts in the anterior mitral leaflets in 2 cases, in cases of ruptured chordae tendineae as a single procedure in one case, and in combination with annuloplasty in 3 cases. Direct suture of the edges cf the anterior mitral leaflet for plication was used when that leaflet was too long and was prolapsed into the atrium (Fig. 1). This plication was then combined with annuloplasty. Direct suture between the valves in the commissures was used once. The annuloplasty: The annuloplastic procedure was applied in a wrong manner in the first 4 cases, as the sutures were applied anteriorly to the com­ missure (Fig. 2). Three patients developed recurrent insufficiency, and in 1, in whom both commissures were narrowed, a remaining stenosis occurred. The narrowing of the annulus with a lasting result can only be made from the commissure to the annulus behind the mural leaflet (Fig. 3). No. 2 silk is used as rupture of weaker suture material was found in 3 cases. The annuloplasty was applied to the lateral commissure in one case, to the medial in 7 cases, and to both commissures in 7 cases. A posterior Ivalon cushion was used in 6 cases, both corners being fixed to the trigona fibrosacordis. C. Investigative Methods.—Follow-up investigation included left heart catheterization with measurement of the diastolic gradient over the mitral ori­ fice to detect remaining stenosis. Left ventricular angiocardiography was also carried out to demonstrate objectively the postoperative presence and degree of mitral insufficiency. The heart size and the ability to perform a work load test were among the more important investigations beside the clinical evaluation.

Fig:. 2.—A and B, Diagrram of the first technique for annuloplasty in which the sutures were applied anteriorly to the commissure at the base of the anterior leaflet.

Figr. 3.—A and B, Diagrram which shows the correct technique for annuloplasty in which the sutures are placed behind the commissure and down to about one third of the mural leaflet.

RESULTS

Deaths.—Seven of the 26 patients died and the findings are summarized in Table I. There were 4 early deaths, due to myocardial failure in 3 and to a hemorrhage from injury of the femoral artery cannula in one ease. As a result, the external iliac artery was subsequently used. There were 3 late deaths, 2, 5, and 12 months after operation, and were all due to mitral insufficiency. In one case a good primary result was obtained with competence for iy2 months. The recurrence was due to the sutures cutting through both commissures. In the second case the sutures were wrongly placed and the suture material ruptured. In the third patient with absence of part of the posterior cusp, there could not

BJÖRK A N D M A L E R S

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J. Thoracic and Cardîovas. Surg.

15 IMPROVED

4 NOT IMPROVED

}

IMS 6MIREC. I BLEEDING

7 DIED

3 FAILURE

2 6 M l AN NU L0 PL A STY Fig. 4.—Diagram of the results obtained in 26 cases of annuloplasty for mitral insufficiency.

be satisfactory repair. The patient was left with an insufficiency, as no prosthesis was available before 1960. After one year the sutures had cut through and Staphylococcus aureus sepsis occurred. The average heart size in the patients was 1,592 ml. (1,120 to 2,350), which corresponds to a relative heart size of 910 ml./M. 2 (630 to 1,350). Complications.—Two patients of the 26 encountered embolie complications without late sequela. One 41-year-old woman (total heart size 950 ml., relative TABLE I. FINDINGS I N T H E 7 PATIENTS W H O DIED PRESSURES ( M M . HG.)

AFTER

HEART SIZE BY X-RAY

PA SYSTOL.

PC MEAN

CASE N O .

AGE (YEARS)

TOTAL ML.

REL. ( M L . / M .2)

1

35

MI + A I

34

11

500

2,350

1,050

2

49

M I + MS + T I + A I

45

28

250

1,170

630

3

16

MI

46

16

150

1,790

1,350

4

29

MI

46

16

50

1,650

940

5

38

MI

17

4

150

1,740

940

6

29

MI + MS

75

28

200

1,120

750

7

35

MI

48

20

900

1,330

720

DIAGNOSIS*

(KPM/ MIN.)

•Ml = mitral insufficiency. AI = aortic insufficiency. MS = mitral stenosis. TI = tricuspid

Vol. 48, No. 2 August. 1964

MITRAL I N S U F F I C I E N C Y

255

8 IMPROVED 3 NOT IMPROVED

10 EMBOLISM

>

8 DIED FAILURE

19 M I STARR Fig. 5.—Diagram of the results obtained in 19 cases of total valve replacement with a StarrEdwards ball valve prosthesis.

size 640 ml./M. 2 ) had a delayed return of consciousness with convulsions after the operation which was probably due to air embolism. She regained conscious­ ness on the second day after operation and then made an uneventful recovery with no residue. The other patient, a 47-year-old woman (total heart size 1,960 ml., relative size 920 ml./M. 2 ), suffered a hemiplegia 3 weeks after operation in spite of prophylactic anticoagulant treatment. The symptoms had disappeared after 2 weeks. No Improvement.—Four of the 26 patients were not improved (Table I I ) . The failure was due in 3 cases to recurrent mitral insufficiency; all the patients

OPEN ANNULOPLASTIC CORRECTION OF MITRAL INSUFFICIENCY HEART WEIGHT AT AUTOPSY (GRAMS)

SURVIVAL TIME

CAUSE OF DEATH

COMMENTS

835

Died at operation

Myocardial failure

Big AI of 2,000 ml./min. during perf. ; pos­ terior cushion locally satisfactory

440

5 da.

Myocardial failure

Mitral annuloplasty + tricuspid posterior cushion repair locally satisfactory

700

5 da.

Myocardial

Posterior cushion locally satisfactory; tolic murmur remaining

600

24 hr.

Hemorrhage from cannulated femoral ar­ tery

Posterior Ivalon cushion locally satisfactory

710

2 mo. ·

Recurrent M I

After 1 mo. no systolic murmur; after 1% mo. MI, sutures had cut through at both lat. and med. commissures

600

5 mo.

Recurrent MI

Suture wrongly placed; suture material rup­ tured

780

1 yr.

MI + infection

One third of posterior cusp absent; primary result bad, suture cutting through; Staph. aureus infection

insufficiency.

failure

sys­

BJÖEK AND M A L E E S

256

J. Thoracic and Cardiovas. Surg.

had been operated upon before 1960 when the technique of annuloplasty was not well understood. The sutures had been placed at the base of the anterior mitral leaflet, anterior to the trigona fibrosa, and had cut through. In one patient in whom this technique was used on both commissures, the insufficiency had been eliminated but a resulting stenosis caused the failure. All of these patients have been advised to have re-operation with total valve replacement; this opera­ tion has already been carried out in one patient and has resulted in significant improvement. Improved Patients.—Fifteen patients who were significantly improved have been followed, and the data are summarized in Table III. The follow-up has been for more than 3 years in 7 patients and 2 years in 3 patients. The largest heart in a surviving patient was 2,100 ml. (1,150 ml./M. 2 ), but the average size was 1,110 ml. (650 ml./M. 2 ) before operation and 1,030 ml. (610 ml./M. 2 ) after opera­ tion. There was no insufficiency demonstrated by angiograms of the left ven­ tricle in 6 patients. A remaining mitral insufficiency of a lesser degree could TABLE

HEART SIZE CASE N O .

AGE (YEARS)

1

34

DIAGNOSIS

OPERATION

M I + M I + A I + TS 1 yr. follow-up Follow-up after 3 yr.

Commissurotomy + 3 sutures wrongly placed through base of anterior valve medially

TOTAL (ML.)

REL. (ML./M.2)

1,100

700

1,040

670

1,270

830

1,450

750

1,280

660

1,140

610

1,170

620

1,920

1,010

1,550

920

MI + MS + A I + TS 34

MI

3 yr. follow-up 49

M I + MS + A I 1 yr. follow-up

MI

Sutures wrongly placed medially in base of anterior mi­ tral leaflet

Dilatation + posterior Ivalon cushion

3 yr. follow-up M I + MS + A I 35

MI

Sutures wrongly placed through base of anterior mitral leaflet in both com­ missures

1 yr. follow-up 3 yr. follow up ♦Four patients did not improve, 3 due to recurrent mitral fFor legend see Table I. TS = tricuspid stenosis.

990 1,700 1,000 1,700 insufficiency, one due to mitral

Vol. 48, No. 2 August, 1964

MITRAL INSUFFICIENCY

257

be demonstrated in 3 patients. No stenosis was found at follow-up in 10 patients. Some mitral stenosis was found in 2 patients with sutures in both lateral and medial commissures and in one patient with a posterior cushion. Only 2 showed a diastolic gradient over the mitral orifice of 10 and 8 mm. Hg, respectively. A significant drop in pulmonary capillary pressure was found in 5 patients and in the pulmonary artery pressure in 4 patients. Six patients showed a sig­ nificant increase in the working capacity. DISCUSSION

In regard to the surgical technique of annuloplasty, some conclusions can be drawn from this experience. First, it is necessary to place the sutures in one end at the trigona fibrosa cordis and never anteriorly to include the annulus of the anterior leaflet. The other end of the sutures should include the annulus behind the mural leaflet. When the sutures were incorrectly placed, including the base of the anterior leaflet, in 5 cases, the sutures cut through in 4 instances. II* PRESSURI

DECREE OF I N S U F ­ FICIENCY

PC

WORK CAPACITY

60

32

400

II-III

39

19

400 (4')

IV

70

34

300 (4')

II-III

15

7

800

20

9

35 50

PA

|

DEGREE STENOSIS (FINGERBREADTHS)

OF

SUBJ. MITRAL GRADIENT

+ (1%)

0

+ (1%)

0

II

0

0

800

III

0

0

20

550

III

+

18

800

5

400

III

+

47

29

300

II

0

40 48

13 20

250 200

0 0

+ +

stenosis c a u s e d b y t h e o p e r a t i o n .

20

COMMENTS

Sutures wrongly placed, cut through Total mitral valve replacement with Starr-Edwards ball valve performed 3 years after first op­ eration Uneventful recovery with immediate im­ provement, 1 yr. observation Sudden pain with re­ current M I one month postoperatively Total value replace­ ment advised Small insufficiency remained primarily Improved during first year, then de­ teriorated Total valve replace­ ment advised No insufficiency re­ maining but a tight mitral stenosis with a 20 mm. H g rest­ ing diastolic gra­ dient Total valve replace­ ment advised

258

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BJÖRK AND MALEBS

Cardiovas. Surg.

TABLE PRESSURE

CASE AGE NO. ( Y E A R S )

HEART SIZE DIAGNOSIS t

OPERATION

PULMONARY CAPILLARY

PULMONARY ARTERY

BE­ FORE

AFTER

BE­ FORE

AFTER

BEFORE

AFTER

680 ( 440)

18

8

20

22

1

16

MI+MS+AI

Dilatation + lat. annulo­ plasty

630 ( 420)

2

32

MI+MS+AI

Dilatation + annuloplasty, lat. + med. commissurotomy

(

840 470)

770 430)

34

14

(10)

(

29

3

26

MI+AI

Med. annuloplasty

(

820 490)

(

920 540)

9

13

20

20

4

30

MI+AI

Med. annuloplasty

(

1,230 720)

660 410)

18

5

40

15

(

1,010 ( 580)

(

860 520)

15

13

30

30

1,550 910)

(

1,190 740)

25

10

42

26

(

(

720 530)

790 490)

14

33

30

(

770 ( 440)

730 440)

23

3

45

22

(

(

1,440 650)

1,400 660)

10

7

22

(

20

5

39

MI+MS+AI

Dilatation + posterior cushion

6

47

MI

Posterior cushion

7

20

MI, cleft value ; primum defect operated 2 yr. earlier

Direct suture

MI+MS

Dilatation + annuloplasty, lat. + med.

8

52

9

24

MI, rup­ tured chordae

Direct valvular suture

10

20

MI

Direct valvular suture + med. annuloplasty

(

690 410)

11

41

MI, rup­ tured chordae

Direct valvular suture + annuloplasty

(

1,160 780)

(

12

36

MI+MS

Dilatation + posterior Ivalon cushion

(

1,350 760)

(

11

21

890 590)

16

33

1,340 770)

27

13

53

MI+ASD

Direct valvular suture

2,100 (1,120)

2,400 (1,260)

10

14

32

MI+MS

Dilatator + med. annulo­ plasty

1,680 (1,150)

1,290 890)

15

(

15

6

MI

19

35

42

50

28 25

530 610 ( 470) ( 410) ♦Fifteen patients were improved following annuloplastic procedures at investigation up to 3 tSee Table I for legend. ASD = atrial septal defect. Med. + lat. annuloplasty

Vol. 48, No. 2 August, 1964

MITRAL

259

INSUFFICIENCY

III*

WORKING CAPACITY (KPM./MIN.)

DEGREE OP INSUFFICIENCY BY ANGIOGRAM

STENOSIS

MITRAL ORIFICE GRADIENT AFTER OP. (MM. H g )

BEFORE

AFTER

BEFORE

AFTER

BEFORE

AFTER

400

500

III

0

+

0

p

400

400

III

0

+

+

10

20

400

400

I

0

0

0

0

0

3 yr. : excellent

600

600

II

0

0

0

0

0

3 yr. : excellent

400

400

II

IV

+

-

0

3 yr. : excellent, insignificant small heart

50

300

III

0

0

0

0

H e m i p l e g i a 3 weeks a f t e r o p e r a ­ tion with c o m p e t e regression; 2 yr. good result

200

400

III

50

400

IV

VI

+

+

0

2 yr. : significant improvement with slight M I and M S

400

800

III

-

0

0

0

1 yr. : improvement with ing M I

REST

WORK

COMMENTS

3

year follow-up: cellent c o n d i t i o n

3

yr. : improved stenosis

2

pregnant, with

yr. : improved, apical murmur

450

III

0

0

1 yr. : improvement

400

III

0

0

y2

remaining

slight

550

II

0

+

+

3 yr. : improvement, remaining stenosis

600

600

II

IV

0

0

3 yr. : improvement with ing M I

III

-

+

-

III

MI,

systolic

remain­

yr. : improvement

400

50

ex­

1 mo.

follow-up

1 mo.

follow-up

no

MI

y e a r s . The figures in p a r e n t h e s e s d e n o t e h e a r t v o l u m e p e r s q u a r e m e t e r of b o d y s u r f a c e a r e a .

but

remain­

260

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J. Thoracic and Cardiovas. Surg.

Sutures in both commissures caused stenosis in 3 cases, 2 of these patients were significantly improved. However, in one case the stenosis was severe enough to require a re-operation with total valve replacement. When an annuloplasty cannot give complete competence with a remaining orifice of IV2 finger breadths, total valve replacement should be undertaken at once. Sutures in both com­ missures will naturally increase the danger of stenosis. Direct sutures in the valvular edge in cases of ruptured chordae tendineae may give some remaining insufficiency (one case) if no annuloplasty is done as well (2 cases). Of the 2 surviving patients with a posterior Ivalon cushion, one is in excellent condition with an insignificant insufficiency after 3 years, the other has, after 3 years, some stenosis (with a diastolic pressure gradient over the mitral valve of 8 mm. H g ) , but no insufficiency. Naturally the myocardial factor is of great importance in the result. The average heart size of the improved patients was 1,110 ml. (610 to 2,100) which corresponds to a relative heart size of 561 ml./M. 2 (410 to 1,150). Only 2 pa­ tients with a relative heart size of more than 1,000 ml./M. 2 survived and were improved. In conclusion, annuloplasty (Fig. 4) has given results far superior to total valve replacement (Fig. 5). It must be remembered, however, that more ad­ vanced cases are found in the group with total valve replacement. The great danger of embolism after total mitral valve replacement will make annulo­ plasty the procedure of choice, whenever possible. SUMMARY

The technique of annuloplasty has been difficult to learn. Correctly applied it will give complete competence at follow-up for 3 years. The correction must avoid a stenosis. If the mitral orifice has to be narrowed to less than l1/^ fingerbreadths, the method should be abandoned in favor of a total valve replace­ ment. As good and lasting results can be obtained by annuloplasty, this tech­ nique is, however, considered the method of choice whenever it is possible to use it with a good local functional result. REFERENCES

1. Bigelow, W. G., Kuypers, P . J., Heimbecker, R. O., and Gunton, R. W. : Clinical Assess­ ment of the Efficiency and Durability of Direct Vision Annuloplasty, Ann. Surg. 154: 320, 1961. 2. Björk, V. O., Lodin, H., and Malers, E . : The Evaluation of the Degree of Mitral Insuf­ ficiency by Selective Left Ventricular Angiocardiography, Am. Heart J . 60: 691, 1960. 3. Gerbode, F., Kerth, W. J., Osborn, J . J., and Selzer, A.: Correction of Mitral Insufficiency by Open Operation, Ann. Surg. 155: 846, 1962. 4. Kay, E. B., Nogueira, C , and Zimmerman, H. A.: Correction of Mitral Insufficiency Under Direct Vision, Circulation 2 1 : 568, 1960. 5. Kay, J . H., Egerton, W. S., and Zubiate, P . : The Surgical Treatment of Mitral Insufficiency and Combined Mitral Stenosis and Insufficiency With Use of the Heart-Lung Ma­ chine, Surgery 50: 67, 1961. 6. Kay, J . H., and Egerton, W. S. : The Eepair of Mitral Insufficiency Associated With Rup­ tured Chordae Tendineae, Ann. Surg. 157: 351, 1963. 7. Kerth, W. J., Gerbode, F., Osborn, J., and Selzer, A.: A New Approach to the Correction of Pure Mitral Insufficiency by Open-Heart Surgery, Am. Heart J . 64: 301, 1962. 8. MeGoon, D. C. : Eepair of Mitral Insufficiency Due to Euptured Chordae Tendineae, J . THORACIC & CARDIOVAS. SURG. 3 9 :

357,

1960.

9. Nichols, H. T., Blanco, G., Uriechio, J . F., and Likoff, W. : Open-Heart Surgery for Mitral Eegurgitation and Stenosis, A. M. A. Areh. Surg. 82: 128, 1961.