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Correction of anterior mitral prolapse
Correction of anterior mitral prolapse Results of chordal transposition From 1986 to 1992 102 mitral valve repairs were done for mitral regurgitation due to a degenerative disease. Forty-eight patients had an anterior prolapse or prolapse of both leaflets at initial presentation and underwent chordal transposition from the mural leaflet to the anterior leaflet The corrective procedure was completed by polytetrafluoroethylene or pericardial posterior annuloplasty. Operative mortality was 2.9 %, and follow-up (average 22 months) was 100% complete. There were three postreconstruction valve replacements (one earlier and two later) for a probability of freedom from reoperation of 91.5% ± 5.2% at 3 years. Freedom from aU morbidity was 85.5% ± 5.5% at 3 years. Postoperative echocardiographic studies demonstrated a good mitral valve function: (1) Eightyseven percent of patients presented no or mild residual regurgitation; (2) transmitral flow indexes were within the norm; (3) left ventricular outflow tract flow was normal in aU patients. This study shows that chordal transposition is a safe and effective technique for prolapse of anterior or both leaflets and improves the chances of repair in patients with mitral degenerative disease. (J THORAC CARDIOVASC SURG 1992;104:1268-73)
Maurizio Salati, MD,a Roberto Scrofani, MD,a Pi no Fundaro, MD,a Alessandro Cialfi, MD,b and Carmine Santoli, MD,a Milan, Italy
Util1983, when Carpentier! described the transposition of chordae from the mural leaflet to the anterior leaflet, the repair of anterior leaflet prolapse was a surgical challenge. In our institution chordal transposition was introduced in 1986. This study concerns 48 patients with anterior leaflet prolapse undergoing chordal transposition in conjunction with other corrective procedures. Patients and methods A total of 102 consecutive patients with mitral regurgitation resulting from a degenerative disease ("floppy valve") underwent heart operations from February 1986 to April 1991. Of these, 48 patients with a prolapse ofthe anterior or both leaflets underwent chordal transposition and entered in the study. All patients presented the usual echographic features of the myxomatous valve disease (leaflet redundancy, mesodiastolic leaflet thickness greater than 5 mm). Mitral leaflet prolapse was diagnosed at two-dimensional echocardiography ifthe full thickness From the Department of Thoracic and Cardiovascular Surgery; Department of Cardiology," "LuigiSacco" Hospital, Milan, Italy. Received for publication Aug. 22, 1991. Accepted for publication March 2, 1992. Address for reprints: Maurizio Salati, MD, Divisione di Chirurgia Toracica e Cardiovascolare, Ospedale "L. Sacco," ViaG.B.Grassi n. 74, 20157 Milano, Italy. 12/1/38384
1268
of any part ofthe leaflet extended through the plane of the mitral anulus into the left atrium. Clinical characteristics. Thirty male and 18 female patients were studied; they ranged in age from 21 to 72 years (mean 57 years). Ten patients were in New York Heart Association (NYHA) class IV, 30 in NYHA class III, 7 in NYHA class II, and I in NYHA class I. Two patients presented a history of mitral endocarditis and two, a history of chronic angina. Eighteen patients (37%) had atrial fibrillation. Ten patients had an associated cardiac disease (aortic regurgitation two, tricuspidal regurgitation five, coronary artery disease two, atrial septal defect one) requiring correction at the time of valve reconstruction. Echocardiographic evaluation. All patients were submitted to a complete two-dimensional echocardiographic examination before undergoing operation, when being discharged from the hospital, and then yearly. All examinations were performed by the same cardiologist (A. C.). Chamber sizes were obtained from M-mode findings. Mitral regurgitation was quantified by means of the regurgitant jet area/left atrium area ratio. The mitral valve area was measured both by the half-time pressure method and by short-axis planimetry. Preoperatively, all patients had a severe (grade 3+) mitral incompetence. Isolated anterior leaflet prolapse was observed in 28 patients while the other 20 presented a prolapse of both leaflets. Operative technique. All operations were done with a standard cardiopulmonary bypass at 28° C. Cold antegrade cardioplegic solution was employed for myocardial protection. The mitral valve was usually approached through a right-sided left atriotomy, but in two patients the transseptal approach was
Volume 104 Number 5
Correction of anterior m itral prolapse
Novemb er 1992
I 269
Table I. Operative fi ndings Chordal pathology
No . ofpatients
ALP Rupture Elongation BLP Anterior rupture and posterior elongation Anterior elongation and posterior rupture Anterior and posterior rupture Anterior and posterior elongation
16 12 5 7 3 5
ALP. Anterior leaflet prolapse; BLP, prolapse of both leaflets.
80 -
--
Table II. Summary ofpertinent clinical data on six patients with moderate or severe residual mitral regurgitation Residual Operative fi ndings
MR
ALP by chordal rupture; annular calcifications BLP by anterior chordal rupture and posterior chordal elongation ALP by chordal elongation
3+
Reoperated
3+
Reoperated
2+
ALP by multiple chordal rupture ALP by chordal elongation ALP by chordal elongation
2+
NYHA class II; LVDD unvaried NYHA class II; LVDD unvaried Reoperated NYHA class I; LVDD reduced
3+
2+
Outcome
M R, Mitr al regurgitation; ALP, a nterior leaflet prolapse; BLP, prolapse of both leaflets; N YHA, New York H eart Association; L VDD. left ventricular d iastolic diameter.
used. Pathologic findings are illustrated in Table I. Twelve patients (25%) presented a complex pathology; anterior chordal rupture and posterior chordal elongation , five; multiple anterior chorda l rupture, four; anterior and posterior chordal rupture, three . Annular calcifications were found in six patients. After careful examination of the mitral valve, a portion of the posterior leaflet of variable width (from I to 2.5 em), including almost two marginal chordae opposite to the prolapsing segment, was detached . This portion of posterior leaflet was sutured to the free edge of the a nterior leaflet with separate stitches (4-0 silk). Th e a nulus immediately beneath the transposed segment of the mural leaflet was folded with pledget-supported stitch es. After this, restrictive a nnuloplasty was performed by adding a polytetrafluoroethylene (PT FE) 4 mm condu it along the posterior anulus just beyond the ana tomic commissures.? In the last 20 patients the PT FE conduit was replaced by autologous pericardium: A strip of pericardium ( I X 8 em ) was prepared and rolled up in a tubular fashion with the serosal surface on the outside.' Thi s pericardial tube was managed in the same manner as the PTFE conduit. Finally, the mur al leaflet was reconstructed by a runn ing 4-0 suture. Posterior annuloplasty was performed in 47 patien ts. In two pati ents with multiple rupture a separate double chorda l transposition was performed. Three patients with a nterior chordal rup ture and posterior chorda l
_ _
47
_
- .
26
31
70 ' - - - - - - ' - - - - - ' - --
o
2
-
18
5
--'----'-----' 5 3
years -e-
Free or reoper,
---- Free or morbidity
Fig. 1. Plot of percent of freedom from mitral valve reoperation and freedom from all morbid ity. Nu mbers of each end-ofinterval mark on the X axis indicate th e number of patients who ent ered that interval. Brackets, ± I stan da rd error.
elongat ion requ ired additional shortening of the tran sposed chordae. All pat ients were placed on a nticoagulation therapy for 3 months postoperati vely. After this period, all pat ients discontinued the anticoagulation and were switched to antiplatelet the rapy. Follow-up evaluation was 100% complete, with an average follow-up time of 22 months (I to 64) . All data a re expressed as mean ± stand ard deviation. The frequency of early and late complicat ions was obtained by the Kaplan-Meier method. The paired t test was used for comparing the results before and after the operation . Fisher's exact test was used when appropriate. Results Operative results. There wa s one ho sp ital death
(2.9%) . This patient d ied suddenly 4 da ys after operation for the po sterior papillary muscle rupture caused b y intra ope ra tive m yocardial infarction. No patient needed inotropic suppo rt or a rtificia l ventila tion for more than 24 hours. One patient required a n early reoperation for severe residual mitral regurgitation. When reconstructing t he va lve, a n ex tensive mural leaflet transposition was done a nd the usu al a nnu lopla sty was not performed because it see m ed too re strictive . During the reoperation co m plete d ehi scence of a nnu la r " plication" a nd mural leafl et suture was found . After m itral replacement, the
12 7 0
The Journal of Thoracic and Cardiovascular Surgery
Salati et af.
EDDl
5.81.!1.72
PRE- OP 10-DAYS 1-YEl\R
MVA
PRE-OP 10-DAYS l-YEAR
_----
P 0,01
N.S
P 0,01
N.S
Fig. 2. Bar graphs of the effect of the operation on echocardiographic findings. End-diastolic diameter index (EDDI,
left panel) falls early and remains unchanged after I year. Mitral valve area (MVA, right panel) presents a significant reduction after the operation. There is no trend toward late dilatation.
Table III. Postoperative evaluation (Doppler analysis)
N' pls.
of transmitral flow 30
59'l>
Flow velocity (rn/sec)
E/A ratio* LVOT flow (rn/sec)
20
Observed values
Normal values
1.05 ± 0.3 1.05 ± 0.5 0.9 ± 0.3
0.9 ± 0.3 1.35 ± 0.6 0.95 ± 0.2
E/A, protodiastolic/telediastolic; LVOT, left ventricular outflow tracl. 'Patients on sinus rhythm.
10
o
GRADE 0+
~ GRADE 1+
CJ
GRADE 2+
IIiII
GRADE 3+
Fig. 3. Postoperative residual mitral regurgitation, early (47 patients) and 1 year (31 patients) echocardiography. There was a stability of residual mitral regurgitation: Only one patient shifted from 0+ to I + after I year.
patient recovered quickly. Neither thromboembolism nor endocarditis occurred in the postoperative course. Follow-up: Clinical evaluation. Two patients needed mitral valve replacement for a reoperation freedom prob-
abilityof91.5% ± 4.7% at 3 years (Fig. I). Among those who were followed up for a longer period, no further events occurred. The other 44 patients were in NYHA class I (32 patients) or II (12 patients). Clinical data and operative findings of the six patients with moderate or severe residual regurgitation are illustrated in Table II. Moderate or severe residual regurgitation was not related to the presence of anterior chordal elongation (p> 0.20) or complex lesions (p > 0.20). No patient had thromboembolic episodes, and two patients had warfarinrelated bleedings. Endocarditis occurred in one patient, without consequences on mitral reconstruction. Freedom from all morbidity was 85.5% ± 5.5% at 3 years (see Fig.
I). Follow-up: Echocardiographic evaluation. Left ventricular dimensions and mitral valve areas are illustrated in Fig. 2. All twelve patients with preoperative high endsystolic left ventricular diameter (>50 mm) had significant reduction of the chamber size. Postoperative mitral
Volume 104 Number 5 November 1992
Correction of anterior mitral prolapse
I 27 I
Fig. 4. Transesophageal four-chamber viewshowsmorphologic changes after the surgical correction. A, Preoperative echocardiogramm. There is a marked superior systolicdisplacement of both leaflets above the annular plane without coaptation point. B, After chordal transpositionand posteriorpericardial annuloplasty, mobility of both leaflets has been normalized. The coaptation point occurson the ventricular side of the annular plane. Transposedchordae, crossing the inflow portion of the left ventricle, are visible.
valve competence is illustrated in Fig. 3, and transmitral flow indexes are depicted in Table III. Four patients demonstrated a mild residual a nterior prolapse with grade I + residual regurgitation. At reconstruction of the valve, these patients presented an anterior prolapse due to chordal elongation. A peculiar pattern of left ventricular filling was observed in most patients (34/47): The diastolic flow showed a curve toward the lateral wall entering
into the inflow tract of the left ventricle. Transposed chordae may be visualized by means of a four-chamber apical view (Fig. 4) .
Discussion
In the past the presence of a sign ificant anterior leaflet prolapse was considered a contraindication for a conservative operation.v" This was because of disappointing
The Journal of Thoracic and Cardiovascular Surgery
I 2 7 2 Sa/ali et a/.
results obtained with other techniques: (1) Triangular resection of the anterior leaflet may be effective only on the small prolapse': 7; (2) chordal shortening procedures have been considered "too complex and therefore too hazardous for the expected benefit of operation'"; and (3) chordal replacement with autologous or synthetic materiaf still lacks a systematic clinical evaluation. Furthermore, the correct evaluation of the natural length of the elongated or ruptured chordae is rather subjective and difficult in the flaccid heart. The potential advantage of chordal transposition is the creation of a new anterior chorda by use of the redundant posterior leaflet. Originally this technique was proposed by Carpentier! for the repair of anterior chordal rupture. We have extended, as have other authors/"!' its use to anterior leaflet prolapse caused by chordal elongation. In these cases the transposed chordae of natural length prevent the exaggerated systolic movement. The choice of the segment of mural leaflet is a compromise between the site of the prolapsing segment of anterior leaflet and the length and quality of the posterior chorda to be transposed. When the transposed chordae seem to be too long (as in the mural leaflet prolapse), they may be shortened by tying them to the free margin of the anterior leaflet. Multiple rupture can be managed by transposing two smaller separate segments or by transposing a very large segment of the posterior leaflet. Chordal transposition is impossible in the presence of a hypoplastic mural leaflet. We encountered this situation only in one case associated with an atrial septal defect and managed by chordal shortening. Our results show that chordal transposition is an effective procedure for the treatment of anterior leaflet prolapse. We performed mitral reconstruction in all patients (100%) with degenerative disease, even in those with complex lesions. Nonetheless, our rate of freedom from reoperation was 91 % at 3 years. This finding agrees with other series of patients with degenerative disease. Most authors reported rates of freedom from reoperation of 88% to 90% at 5 years. 12- 14 We found that chordal elongation and complex lesions did not represent a considerable hazard for mitral reconstruction. The presence of a posterior chordal elongation did not affect the success of repair. In most cases, the tethering effect of the suture compensated the excessive length of the posterior chordae. In fact, only four patients exhibited a mild residual anterior leaflet prolapse without consequences on the valvular competence. Functional results are encouraging. The end-diastolic diameter fell early and remained stable during the follow-up, even in patients with moderate residual regurgitation. All patients with preoperative high left ventric-
ular end-systolic dimension showed a significant reduction of the left heart size; these findings were not observed by Shuler and coworkers in similar patients undergoing mitral valve replacement.P Color flow imaging allowed us to illustrate excellent postoperative valve competence, similar to that reported by Galloway and colleagues'{ at New York University (83% with grade 0+ or 1+, 10% with grade 2+, and 7% with grade 3+). This technique does not affect the transmitral flow pattern. We did not find any significant gradient despite the presence of a "heavy" anterior mitral leaflet; transmitral flow indexes seem to indicate an almost physiologic flow. The only unusual finding concerned the deviation ofthe transmitral flow toward the lateral wall of the left ventricle. This is probably due to the new spatial relationship in the chordal architecture. Annular remodeling is a crucial point of the correction. It reduces the anulus size, distributes the tension of the suture on the posterior anulus, and prevents a late annular dilation. Our type of annuloplasty avoids the negative effect of the rigid fixation of the mitral anulus.lv 17 The postoperative mitral valve area was satisfactory, and no patients exhibited left ventricular outflow tract obstruction, as observed by some authors in patients with Carpentier ring. 18, 19 In conclusion, chordal transposition seems to be a safe and effective technique for the treatment of anterior leaflet prolapse. This procedure can be used successfully even in patients with complex lesions, and it improves the predictability of repair. If the long-term results confirm the midterm findings, this technique will represent a real turning point in mitral conservative operations. We are grateful to A. Salvaggio, MD, for statistical assistance.
1.
2. 3. 4. 5. 6.
REFERENCES Carpentier A. Cardiac valve surgery: the" Frenchcorrection." J THORAC CARDIOVASC SURG 1983;86:323-37. Fundaro'P, Salati M, CialfiA, Santoli C. Polytetrafluoroethylene posterior annuloplasty for mitral regurgitation. Ann Thorac Surg 1990;50:165-6. Salati M, Scrofani R, Santoli C. Posterior pericardial annuloplasty: a physiological correction? Eur J Cardiothorae Surg 1991;5:226-9. Oliveira DBG,Dawkins KD, Kay PH, Paneth M. Chordal rupture. Comparison between repair and replacement. Br Heart J 1983;50:318-24. Oury JH, Kirk LP, Folkerth TL, Daily PO. Mitral valve replacement versus reconstruction. J THORAC CARDIOVASC SURG 1976;825-33. Dawkins KD,Paneth M. Mitralvalve repairversus replacement. J THORAC CARDIOVASC SURG 1986;91:150-1.
Volume 104 Number 5
Correction of anterior mitral prolapse
November 1992
7. Carpentier A, Fabiani IN, Reiland J, D'Allaines CL, Piwnica A. Reconstructive surgery of mitral incompetence. J THORAC CARDIOVASC SURG 1980;79:338-48. 8. Frater RWM, Gabbay S, Shore D, Factor S, Strom J. Reproducible replacement of elongated or ruptured mitral valve chordae. Ann Thorac Surg 1983;35:14-24. 9. Duran CG. Repair of anterior mitral leaflet with chordal rupture or elongation (the flip over technique). J THORAC CARDIOVASC SURG 1986;1:161-6. 10. Lessana' A, Escorsin M, Romano M, et al. Transposition of posterior leaflet for treatment of ruptured chordae of the anterior mitral leaflet. J THORAC CARDIOVASC SURG 1989;89:804-6. II. Salati M, Di Biasi P, Fundaro' P, Santoli C. Transposition of chordae in floppy mitral valve repair. In: Ghosh PK, Ungher F, eds. Cardiac Reconstruction. Berlin: Springer, 1989:171-5. 12. Galloway A, Colwin S, Bauman G, et al. Long term results of mitral valve reconstruction with Carpentier techniques in 148 patients with mitral insufficiency. Circulation 1988;78 (Pt 2):197-105. 13. Cohn LH, Di Sesa J, Couper G, et al. Mitral valve repair
14. 15.
16.
17.
18.
19.
127 3
for myxomatous degeneration and prolapse of mitral valve. J THORAC CARDIOVASC SURG 1989;98:987-93. Galloway A, Colvin S, Bauman G, et al. Current concepts of mitral insufficiency. Circulation 1988;78:1087-98. Shuler G, Peterson KL, Johnson A, et al. Temporal response of ventricular performance to mitral valve surgery. Circulation 1979;59:1218. Rijk-Zwikker GL, Skipperhein JJ, Huismans A, Bruschke A. Influence of mitral ring on left ventricular pump function. Circulation I 989;80(Pt 2):11-7. David TE, Komedo M, Pollick C, Burns RJ. Mitral valve annuloplasty: the effect of the type on left ventricular function. Ann Thorac Surg 1989;47:524-8. Schiavone WA, Cosgrove DM, Lever HM, Steward WJ, Salcedo EE. Long term follow-up of patients with left ventricular outflow tract obstruction after Carpentier ring mitral valvuloplasty. Circulation 1988;78(Pt 2):160-5. Galler M, Kronzon I, Slater J, et al. Long term follow-up after mitral valve reconstruction: incidence of postoperative left ventricular obstruction. Circulation I 986;74(Pt 2)199103.
Maurizio Salati, MD,a Roberto Scrofani, MD,a Pi no Fundaro, MD,a Alessandro Cialfi, MD,b and Carmine Santoli, MD,a Milan, Italy
Util1983, when Carpentier! described the transposition of chordae from the mural leaflet to the anterior leaflet, the repair of anterior leaflet prolapse was a surgical challenge. In our institution chordal transposition was introduced in 1986. This study concerns 48 patients with anterior leaflet prolapse undergoing chordal transposition in conjunction with other corrective procedures. Patients and methods A total of 102 consecutive patients with mitral regurgitation resulting from a degenerative disease ("floppy valve") underwent heart operations from February 1986 to April 1991. Of these, 48 patients with a prolapse ofthe anterior or both leaflets underwent chordal transposition and entered in the study. All patients presented the usual echographic features of the myxomatous valve disease (leaflet redundancy, mesodiastolic leaflet thickness greater than 5 mm). Mitral leaflet prolapse was diagnosed at two-dimensional echocardiography ifthe full thickness From the Department of Thoracic and Cardiovascular Surgery; Department of Cardiology," "LuigiSacco" Hospital, Milan, Italy. Received for publication Aug. 22, 1991. Accepted for publication March 2, 1992. Address for reprints: Maurizio Salati, MD, Divisione di Chirurgia Toracica e Cardiovascolare, Ospedale "L. Sacco," ViaG.B.Grassi n. 74, 20157 Milano, Italy. 12/1/38384
1268
of any part ofthe leaflet extended through the plane of the mitral anulus into the left atrium. Clinical characteristics. Thirty male and 18 female patients were studied; they ranged in age from 21 to 72 years (mean 57 years). Ten patients were in New York Heart Association (NYHA) class IV, 30 in NYHA class III, 7 in NYHA class II, and I in NYHA class I. Two patients presented a history of mitral endocarditis and two, a history of chronic angina. Eighteen patients (37%) had atrial fibrillation. Ten patients had an associated cardiac disease (aortic regurgitation two, tricuspidal regurgitation five, coronary artery disease two, atrial septal defect one) requiring correction at the time of valve reconstruction. Echocardiographic evaluation. All patients were submitted to a complete two-dimensional echocardiographic examination before undergoing operation, when being discharged from the hospital, and then yearly. All examinations were performed by the same cardiologist (A. C.). Chamber sizes were obtained from M-mode findings. Mitral regurgitation was quantified by means of the regurgitant jet area/left atrium area ratio. The mitral valve area was measured both by the half-time pressure method and by short-axis planimetry. Preoperatively, all patients had a severe (grade 3+) mitral incompetence. Isolated anterior leaflet prolapse was observed in 28 patients while the other 20 presented a prolapse of both leaflets. Operative technique. All operations were done with a standard cardiopulmonary bypass at 28° C. Cold antegrade cardioplegic solution was employed for myocardial protection. The mitral valve was usually approached through a right-sided left atriotomy, but in two patients the transseptal approach was
Volume 104 Number 5
Correction of anterior m itral prolapse
Novemb er 1992
I 269
Table I. Operative fi ndings Chordal pathology
No . ofpatients
ALP Rupture Elongation BLP Anterior rupture and posterior elongation Anterior elongation and posterior rupture Anterior and posterior rupture Anterior and posterior elongation
16 12 5 7 3 5
ALP. Anterior leaflet prolapse; BLP, prolapse of both leaflets.
80 -
--
Table II. Summary ofpertinent clinical data on six patients with moderate or severe residual mitral regurgitation Residual Operative fi ndings
MR
ALP by chordal rupture; annular calcifications BLP by anterior chordal rupture and posterior chordal elongation ALP by chordal elongation
3+
Reoperated
3+
Reoperated
2+
ALP by multiple chordal rupture ALP by chordal elongation ALP by chordal elongation
2+
NYHA class II; LVDD unvaried NYHA class II; LVDD unvaried Reoperated NYHA class I; LVDD reduced
3+
2+
Outcome
M R, Mitr al regurgitation; ALP, a nterior leaflet prolapse; BLP, prolapse of both leaflets; N YHA, New York H eart Association; L VDD. left ventricular d iastolic diameter.
used. Pathologic findings are illustrated in Table I. Twelve patients (25%) presented a complex pathology; anterior chordal rupture and posterior chordal elongation , five; multiple anterior chorda l rupture, four; anterior and posterior chordal rupture, three . Annular calcifications were found in six patients. After careful examination of the mitral valve, a portion of the posterior leaflet of variable width (from I to 2.5 em), including almost two marginal chordae opposite to the prolapsing segment, was detached . This portion of posterior leaflet was sutured to the free edge of the a nterior leaflet with separate stitches (4-0 silk). Th e a nulus immediately beneath the transposed segment of the mural leaflet was folded with pledget-supported stitch es. After this, restrictive a nnuloplasty was performed by adding a polytetrafluoroethylene (PT FE) 4 mm condu it along the posterior anulus just beyond the ana tomic commissures.? In the last 20 patients the PT FE conduit was replaced by autologous pericardium: A strip of pericardium ( I X 8 em ) was prepared and rolled up in a tubular fashion with the serosal surface on the outside.' Thi s pericardial tube was managed in the same manner as the PTFE conduit. Finally, the mur al leaflet was reconstructed by a runn ing 4-0 suture. Posterior annuloplasty was performed in 47 patien ts. In two pati ents with multiple rupture a separate double chorda l transposition was performed. Three patients with a nterior chordal rup ture and posterior chorda l
_ _
47
_
- .
26
31
70 ' - - - - - - ' - - - - - ' - --
o
2
-
18
5
--'----'-----' 5 3
years -e-
Free or reoper,
---- Free or morbidity
Fig. 1. Plot of percent of freedom from mitral valve reoperation and freedom from all morbid ity. Nu mbers of each end-ofinterval mark on the X axis indicate th e number of patients who ent ered that interval. Brackets, ± I stan da rd error.
elongat ion requ ired additional shortening of the tran sposed chordae. All pat ients were placed on a nticoagulation therapy for 3 months postoperati vely. After this period, all pat ients discontinued the anticoagulation and were switched to antiplatelet the rapy. Follow-up evaluation was 100% complete, with an average follow-up time of 22 months (I to 64) . All data a re expressed as mean ± stand ard deviation. The frequency of early and late complicat ions was obtained by the Kaplan-Meier method. The paired t test was used for comparing the results before and after the operation . Fisher's exact test was used when appropriate. Results Operative results. There wa s one ho sp ital death
(2.9%) . This patient d ied suddenly 4 da ys after operation for the po sterior papillary muscle rupture caused b y intra ope ra tive m yocardial infarction. No patient needed inotropic suppo rt or a rtificia l ventila tion for more than 24 hours. One patient required a n early reoperation for severe residual mitral regurgitation. When reconstructing t he va lve, a n ex tensive mural leaflet transposition was done a nd the usu al a nnu lopla sty was not performed because it see m ed too re strictive . During the reoperation co m plete d ehi scence of a nnu la r " plication" a nd mural leafl et suture was found . After m itral replacement, the
12 7 0
The Journal of Thoracic and Cardiovascular Surgery
Salati et af.
EDDl
5.81.!1.72
PRE- OP 10-DAYS 1-YEl\R
MVA
PRE-OP 10-DAYS l-YEAR
_----
P 0,01
N.S
P 0,01
N.S
Fig. 2. Bar graphs of the effect of the operation on echocardiographic findings. End-diastolic diameter index (EDDI,
left panel) falls early and remains unchanged after I year. Mitral valve area (MVA, right panel) presents a significant reduction after the operation. There is no trend toward late dilatation.
Table III. Postoperative evaluation (Doppler analysis)
N' pls.
of transmitral flow 30
59'l>
Flow velocity (rn/sec)
E/A ratio* LVOT flow (rn/sec)
20
Observed values
Normal values
1.05 ± 0.3 1.05 ± 0.5 0.9 ± 0.3
0.9 ± 0.3 1.35 ± 0.6 0.95 ± 0.2
E/A, protodiastolic/telediastolic; LVOT, left ventricular outflow tracl. 'Patients on sinus rhythm.
10
o
GRADE 0+
~ GRADE 1+
CJ
GRADE 2+
IIiII
GRADE 3+
Fig. 3. Postoperative residual mitral regurgitation, early (47 patients) and 1 year (31 patients) echocardiography. There was a stability of residual mitral regurgitation: Only one patient shifted from 0+ to I + after I year.
patient recovered quickly. Neither thromboembolism nor endocarditis occurred in the postoperative course. Follow-up: Clinical evaluation. Two patients needed mitral valve replacement for a reoperation freedom prob-
abilityof91.5% ± 4.7% at 3 years (Fig. I). Among those who were followed up for a longer period, no further events occurred. The other 44 patients were in NYHA class I (32 patients) or II (12 patients). Clinical data and operative findings of the six patients with moderate or severe residual regurgitation are illustrated in Table II. Moderate or severe residual regurgitation was not related to the presence of anterior chordal elongation (p> 0.20) or complex lesions (p > 0.20). No patient had thromboembolic episodes, and two patients had warfarinrelated bleedings. Endocarditis occurred in one patient, without consequences on mitral reconstruction. Freedom from all morbidity was 85.5% ± 5.5% at 3 years (see Fig.
I). Follow-up: Echocardiographic evaluation. Left ventricular dimensions and mitral valve areas are illustrated in Fig. 2. All twelve patients with preoperative high endsystolic left ventricular diameter (>50 mm) had significant reduction of the chamber size. Postoperative mitral
Volume 104 Number 5 November 1992
Correction of anterior mitral prolapse
I 27 I
Fig. 4. Transesophageal four-chamber viewshowsmorphologic changes after the surgical correction. A, Preoperative echocardiogramm. There is a marked superior systolicdisplacement of both leaflets above the annular plane without coaptation point. B, After chordal transpositionand posteriorpericardial annuloplasty, mobility of both leaflets has been normalized. The coaptation point occurson the ventricular side of the annular plane. Transposedchordae, crossing the inflow portion of the left ventricle, are visible.
valve competence is illustrated in Fig. 3, and transmitral flow indexes are depicted in Table III. Four patients demonstrated a mild residual a nterior prolapse with grade I + residual regurgitation. At reconstruction of the valve, these patients presented an anterior prolapse due to chordal elongation. A peculiar pattern of left ventricular filling was observed in most patients (34/47): The diastolic flow showed a curve toward the lateral wall entering
into the inflow tract of the left ventricle. Transposed chordae may be visualized by means of a four-chamber apical view (Fig. 4) .
Discussion
In the past the presence of a sign ificant anterior leaflet prolapse was considered a contraindication for a conservative operation.v" This was because of disappointing
The Journal of Thoracic and Cardiovascular Surgery
I 2 7 2 Sa/ali et a/.
results obtained with other techniques: (1) Triangular resection of the anterior leaflet may be effective only on the small prolapse': 7; (2) chordal shortening procedures have been considered "too complex and therefore too hazardous for the expected benefit of operation'"; and (3) chordal replacement with autologous or synthetic materiaf still lacks a systematic clinical evaluation. Furthermore, the correct evaluation of the natural length of the elongated or ruptured chordae is rather subjective and difficult in the flaccid heart. The potential advantage of chordal transposition is the creation of a new anterior chorda by use of the redundant posterior leaflet. Originally this technique was proposed by Carpentier! for the repair of anterior chordal rupture. We have extended, as have other authors/"!' its use to anterior leaflet prolapse caused by chordal elongation. In these cases the transposed chordae of natural length prevent the exaggerated systolic movement. The choice of the segment of mural leaflet is a compromise between the site of the prolapsing segment of anterior leaflet and the length and quality of the posterior chorda to be transposed. When the transposed chordae seem to be too long (as in the mural leaflet prolapse), they may be shortened by tying them to the free margin of the anterior leaflet. Multiple rupture can be managed by transposing two smaller separate segments or by transposing a very large segment of the posterior leaflet. Chordal transposition is impossible in the presence of a hypoplastic mural leaflet. We encountered this situation only in one case associated with an atrial septal defect and managed by chordal shortening. Our results show that chordal transposition is an effective procedure for the treatment of anterior leaflet prolapse. We performed mitral reconstruction in all patients (100%) with degenerative disease, even in those with complex lesions. Nonetheless, our rate of freedom from reoperation was 91 % at 3 years. This finding agrees with other series of patients with degenerative disease. Most authors reported rates of freedom from reoperation of 88% to 90% at 5 years. 12- 14 We found that chordal elongation and complex lesions did not represent a considerable hazard for mitral reconstruction. The presence of a posterior chordal elongation did not affect the success of repair. In most cases, the tethering effect of the suture compensated the excessive length of the posterior chordae. In fact, only four patients exhibited a mild residual anterior leaflet prolapse without consequences on the valvular competence. Functional results are encouraging. The end-diastolic diameter fell early and remained stable during the follow-up, even in patients with moderate residual regurgitation. All patients with preoperative high left ventric-
ular end-systolic dimension showed a significant reduction of the left heart size; these findings were not observed by Shuler and coworkers in similar patients undergoing mitral valve replacement.P Color flow imaging allowed us to illustrate excellent postoperative valve competence, similar to that reported by Galloway and colleagues'{ at New York University (83% with grade 0+ or 1+, 10% with grade 2+, and 7% with grade 3+). This technique does not affect the transmitral flow pattern. We did not find any significant gradient despite the presence of a "heavy" anterior mitral leaflet; transmitral flow indexes seem to indicate an almost physiologic flow. The only unusual finding concerned the deviation ofthe transmitral flow toward the lateral wall of the left ventricle. This is probably due to the new spatial relationship in the chordal architecture. Annular remodeling is a crucial point of the correction. It reduces the anulus size, distributes the tension of the suture on the posterior anulus, and prevents a late annular dilation. Our type of annuloplasty avoids the negative effect of the rigid fixation of the mitral anulus.lv 17 The postoperative mitral valve area was satisfactory, and no patients exhibited left ventricular outflow tract obstruction, as observed by some authors in patients with Carpentier ring. 18, 19 In conclusion, chordal transposition seems to be a safe and effective technique for the treatment of anterior leaflet prolapse. This procedure can be used successfully even in patients with complex lesions, and it improves the predictability of repair. If the long-term results confirm the midterm findings, this technique will represent a real turning point in mitral conservative operations. We are grateful to A. Salvaggio, MD, for statistical assistance.
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2. 3. 4. 5. 6.
REFERENCES Carpentier A. Cardiac valve surgery: the" Frenchcorrection." J THORAC CARDIOVASC SURG 1983;86:323-37. Fundaro'P, Salati M, CialfiA, Santoli C. Polytetrafluoroethylene posterior annuloplasty for mitral regurgitation. Ann Thorac Surg 1990;50:165-6. Salati M, Scrofani R, Santoli C. Posterior pericardial annuloplasty: a physiological correction? Eur J Cardiothorae Surg 1991;5:226-9. Oliveira DBG,Dawkins KD, Kay PH, Paneth M. Chordal rupture. Comparison between repair and replacement. Br Heart J 1983;50:318-24. Oury JH, Kirk LP, Folkerth TL, Daily PO. Mitral valve replacement versus reconstruction. J THORAC CARDIOVASC SURG 1976;825-33. Dawkins KD,Paneth M. Mitralvalve repairversus replacement. J THORAC CARDIOVASC SURG 1986;91:150-1.
Volume 104 Number 5
Correction of anterior mitral prolapse
November 1992
7. Carpentier A, Fabiani IN, Reiland J, D'Allaines CL, Piwnica A. Reconstructive surgery of mitral incompetence. J THORAC CARDIOVASC SURG 1980;79:338-48. 8. Frater RWM, Gabbay S, Shore D, Factor S, Strom J. Reproducible replacement of elongated or ruptured mitral valve chordae. Ann Thorac Surg 1983;35:14-24. 9. Duran CG. Repair of anterior mitral leaflet with chordal rupture or elongation (the flip over technique). J THORAC CARDIOVASC SURG 1986;1:161-6. 10. Lessana' A, Escorsin M, Romano M, et al. Transposition of posterior leaflet for treatment of ruptured chordae of the anterior mitral leaflet. J THORAC CARDIOVASC SURG 1989;89:804-6. II. Salati M, Di Biasi P, Fundaro' P, Santoli C. Transposition of chordae in floppy mitral valve repair. In: Ghosh PK, Ungher F, eds. Cardiac Reconstruction. Berlin: Springer, 1989:171-5. 12. Galloway A, Colwin S, Bauman G, et al. Long term results of mitral valve reconstruction with Carpentier techniques in 148 patients with mitral insufficiency. Circulation 1988;78 (Pt 2):197-105. 13. Cohn LH, Di Sesa J, Couper G, et al. Mitral valve repair
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