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Partial Translocation for Repair of Left Ventricular Rupture After Mitral Valve Replacement
HOW TO DO IT
Partial Translocation for Repair of Left Ventricular Rupture After Mitral Valve Replacement Hitoshi Yaku, MD, PhD, Yasuyuki Shimada, MD, PhD, Yoshiaki Yamada, MD, Kyoko Hayashida, MD, Atsushi Fukumoto, MD, Taiji Watanabe, MD, and Nobuo Kitamura, MD, PhD
A new partial translocation technique to repair left ventricular rupture after mitral valve replacement and reimplant a mitral prosthesis is described. We repaired a tear from the interior by using mattress stitches buttressed with strips of Dacron felt, constructed a new annulus with a crescent-shaped piece of bovine pericardium on the left atrial wall above the repaired mitral annulus, and
implanted a new prosthesis by using the newly constructed mitral annulus. We consider avoidance of mechanical stress by the prosthesis on the repaired site crucial to a successful outcome, and this new method is useful. (Ann Thorac Surg 2004;78:1851–3) © 2004 by The Society of Thoracic Surgeons
L
Technique
eft ventricular rupture is a rare but potentially lethal complication of mitral valve replacement. Several techniques for the repair of left ventricular rupture have been described and found to be useful [1– 4]. In type I rupture [5], which affects the annulus posteriorly, repair is complicated by 2 factors: (1) the circumflex coronary artery is located near the rupture site and (2) the mitral prosthesis has to be reimplanted exactly at the repair site. To overcome those problems, my colleagues and I developed a new partial translocation technique to repair left ventricular rupture and reimplant a mitral prosthesis. A 74-year-old man who had rheumatic mitral valve disease with chronic atrial fibrillation was referred to our hospital for surgical treatment. He was small and cachectic, with a body weight of 35 kg, a height of 146 cm, and a body-surface area of 1.0 m2. Echocardiography revealed a sclerotic mitral valve with a valve orifice area of 0.7 cm2 and severe fusion of the subvalvular apparatus. Operation was performed on June 7, 2001. A median sternotomy was performed, and the mitral valve was exposed through a combined superior and transseptal approach to the left atrium. The mitral valve was replaced with a 27-mm Mosaic bioprosthesis (Medtronic Inc, Minneapolis, MN). The aortic cross-clamp time was 77 minutes, and the total cardiopulmonary bypass time was 117 minutes. Weaning from cardiopulmonary bypass was uneventful; however, excessive bleeding from the posterior wall of the left ventricle was found near the atrioventricular groove facing the left atrial appendage.
Cardiopulmonary bypass was reestablished, and the mitral valve was exposed through the same approach as that used previously. After the mitral prosthesis was explanted, a 4-cm-long tear involving the endocardium and muscle of the posterior wall was found along the posterior mitral annulus. Nine mattress stitches buttressed with strips of Dacron (DuPont, Wilmington, DE) felt were put from the intact endocardium of the left ventricle through the deep layer of the muscle and pulled through the mitral annulus (Fig 1A). Before tying, gelatinresorcin-formalin (GRF) glue (Cardial SA, Saint-Etienne, France) was put on the tear. A crescent-shaped piece of bovine pericardium (Tissue Guard; Synovis Life Technologies, St. Paul, MN) was then sutured on the left atrial wall above the repaired mitral annulus with 5-0 Prolene continuous sutures (Ethicon Inc, Somerville, NJ), thus creating a new posterior annulus. Fourteen pledgeted mattress sutures were placed through the native annulus anteriorly and the newly constructed annulus posteriorly (Fig 1B). A 25-mm Mosaic bioprosthesis was implanted in a paraannular fashion (Fig 2). The total aortic cross-clamp time was 146 minutes, and the total cardiopulmonary bypass time was 187 minutes. Weaning from bypass was uneventful, with a low dose of catecholamines. There was no clinically appreciable bleeding from the left ventricular wall. The postoperative course was uneventful, except for peroneal nerve palsy of the right foot (drop foot). Postoperative echocardiography results are shown in Figure 3. There was no marked mitral regurgitation. He was transferred to a local hospital for further rehabilitation on the 22nd postoperative day.
Accepted for publication Sept 18, 2003. Address reprint requests to Dr Yaku, Department of Cardiovascular Surgery, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto 602-8566, Japan; e-mail: [email protected].
© 2004 by The Society of Thoracic Surgeons Published by Elsevier Inc
Comment Rupture of the left ventricle after mitral valve replacement is classified into 3 types [5]. Type I rupture is the 0003-4975/04/$30.00 doi:10.1016/j.athoracsur.2003.09.096
FEATURE ARTICLES
Department of Cardiovascular Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
1852
HOW TO DO IT YAKU ET AL REPAIR OF LV RUPTURE AFTER MVR
Ann Thorac Surg 2004;78:1851–3
FEATURE ARTICLES
Fig 2. Schematic diagram illustrating the partial translocation method for repair of a left ventricular rupture. The tear in the posterior wall of the left ventricle was repaired with mattress sutures buttressed with strips of felt, and the posterior mitral annulus was newly constructed with a crescent-shaped piece of bovine pericardium. A Mosaic bioprosthesis was reimplanted at the native annulus anteriorly and newly constructed annulus posteriorly.
with the internal approach [4]. In addition, although the tear may involve the suture line of the previously placed mitral prosthesis, securing the prosthesis from the exterior of the heart is difficult. The internal method is considered the safest and most successful approach, even though the previously placed prosthesis has to be explanted during cardiopulmonary bypass [4]. Internal repair includes direct closure of the tear with multiple horizontal mattress stitches buttressed with felt [4], patch closure of the tear [2], and covering the tear with a patch sutured on the intact endocardium of the ventricle and the left atrium across the annulus [3]. Fig 1. (A) Nine mattress stitches buttressed with Dacron felt were placed from the intact endocardium of the left ventricle through the deep layer of the muscle and pulled through the mitral annulus. (B) A crescent-shaped piece of bovine pericardium was sutured on the left atrial wall above the repaired mitral annulus. Pledgeted mattress sutures for implantation of a prosthesis were placed through the native annulus anteriorly and the newly constructed annulus posteriorly.
most troublesome because the tear is very close to the atrioventricular groove, making it difficult to close the tear completely without damaging the left circumflex artery and coronary sinus. Several surgical techniques for the repair of left ventricular rupture, including both internal and external approaches, have been described [1– 4]. The external approach is complicated by the fact that the internal disruption site and the external bleeding point are often at different locations; moreover, the circumflex coronary artery is more prone to injury with this approach than
Fig 3. Four-chamber view of echocardiography on the 10th postoperative day. Mitral regurgitation was trivial. (LA ⫽ left atrium; LV ⫽ left ventricle.)
Ann Thorac Surg 2004;78:1851–3
1853
ventricular rupture is a fatal complication, and we consider complete hemostasis at the tear site to be the most important factor at the time of the operation. We have to observe the patient carefully because of the risk of a pseudoaneurysm developing at the repaired site.
References 1. Engelman RM, Rousou JH, Wittenberg SA. New technique for repair of posterior left ventricular rupture. J Thorac Cardiovasc Surg 1979;77:757–9. 2. David TE. Left ventricular rupture after mitral valve replacement: endocardial repair with pericardial patch. J Thorac Cardiovasc Surg 1987;93:935–6. 3. Clemin D, Nunez L, Gil-Aguado M, Larrea JL. Intraventricular patch repair of left ventricular rupture following mitral valve replacement: new technique. Ann Thorac Surg 1982;33: 638 –40. 4. Reardon MJ, Letsou GV, Reardon PR, Baldwin JC. Left ventricular rupture following mitral valve replacement. J Heart Valve Dis 1996;5:10 –5. 5. Treasure RL, Rainer WG, Strevey TE, Sadler TR. Intraoperative left ventricular rupture associated with mitral valve replacement. Chest 1974;66:511–4. 6. Bingley JA, Gardner MAH, Stafford EG, et al. Late complications of tissue glues in aortic surgery. Ann Thorac Surg 2000;69:1764 –8.
FEATURE ARTICLES
There should be some tension at the site where the pledgeted mattress sutures are placed with this technique as compared with the patch exclusion technique. However, because the ventricular muscle where we placed the pledgeted mattress sutures was normal— neither infarcted nor damaged—we were able to close the tear more securely and thereby avoid bleeding from the repaired site. Moreover, because the pledgeted mattress stitches were not transmural to the ventricular muscle, we could avoid injury to the circumflex artery at the atrioventricular groove. We consider avoidance of mechanical stress by the prosthesis on the repaired site crucial to a successful outcome. We therefore constructed a new annulus with bovine pericardium apart from the repaired site and implanted a new prosthesis by using the newly constructed mitral annulus. We call this technique partial translocation of the mitral annulus. With this method, postoperative mitral regurgitation was not considerable, and there was no unexpected bleeding from the repaired site. We used GRF glue at the repaired site in this patient. GRF glue has been reported to subsequently cause some tissue deterioration where it was used [6]. However,
HOW TO DO IT YAKU ET AL REPAIR OF LV RUPTURE AFTER MVR
Partial Translocation for Repair of Left Ventricular Rupture After Mitral Valve Replacement Hitoshi Yaku, MD, PhD, Yasuyuki Shimada, MD, PhD, Yoshiaki Yamada, MD, Kyoko Hayashida, MD, Atsushi Fukumoto, MD, Taiji Watanabe, MD, and Nobuo Kitamura, MD, PhD
A new partial translocation technique to repair left ventricular rupture after mitral valve replacement and reimplant a mitral prosthesis is described. We repaired a tear from the interior by using mattress stitches buttressed with strips of Dacron felt, constructed a new annulus with a crescent-shaped piece of bovine pericardium on the left atrial wall above the repaired mitral annulus, and
implanted a new prosthesis by using the newly constructed mitral annulus. We consider avoidance of mechanical stress by the prosthesis on the repaired site crucial to a successful outcome, and this new method is useful. (Ann Thorac Surg 2004;78:1851–3) © 2004 by The Society of Thoracic Surgeons
L
Technique
eft ventricular rupture is a rare but potentially lethal complication of mitral valve replacement. Several techniques for the repair of left ventricular rupture have been described and found to be useful [1– 4]. In type I rupture [5], which affects the annulus posteriorly, repair is complicated by 2 factors: (1) the circumflex coronary artery is located near the rupture site and (2) the mitral prosthesis has to be reimplanted exactly at the repair site. To overcome those problems, my colleagues and I developed a new partial translocation technique to repair left ventricular rupture and reimplant a mitral prosthesis. A 74-year-old man who had rheumatic mitral valve disease with chronic atrial fibrillation was referred to our hospital for surgical treatment. He was small and cachectic, with a body weight of 35 kg, a height of 146 cm, and a body-surface area of 1.0 m2. Echocardiography revealed a sclerotic mitral valve with a valve orifice area of 0.7 cm2 and severe fusion of the subvalvular apparatus. Operation was performed on June 7, 2001. A median sternotomy was performed, and the mitral valve was exposed through a combined superior and transseptal approach to the left atrium. The mitral valve was replaced with a 27-mm Mosaic bioprosthesis (Medtronic Inc, Minneapolis, MN). The aortic cross-clamp time was 77 minutes, and the total cardiopulmonary bypass time was 117 minutes. Weaning from cardiopulmonary bypass was uneventful; however, excessive bleeding from the posterior wall of the left ventricle was found near the atrioventricular groove facing the left atrial appendage.
Cardiopulmonary bypass was reestablished, and the mitral valve was exposed through the same approach as that used previously. After the mitral prosthesis was explanted, a 4-cm-long tear involving the endocardium and muscle of the posterior wall was found along the posterior mitral annulus. Nine mattress stitches buttressed with strips of Dacron (DuPont, Wilmington, DE) felt were put from the intact endocardium of the left ventricle through the deep layer of the muscle and pulled through the mitral annulus (Fig 1A). Before tying, gelatinresorcin-formalin (GRF) glue (Cardial SA, Saint-Etienne, France) was put on the tear. A crescent-shaped piece of bovine pericardium (Tissue Guard; Synovis Life Technologies, St. Paul, MN) was then sutured on the left atrial wall above the repaired mitral annulus with 5-0 Prolene continuous sutures (Ethicon Inc, Somerville, NJ), thus creating a new posterior annulus. Fourteen pledgeted mattress sutures were placed through the native annulus anteriorly and the newly constructed annulus posteriorly (Fig 1B). A 25-mm Mosaic bioprosthesis was implanted in a paraannular fashion (Fig 2). The total aortic cross-clamp time was 146 minutes, and the total cardiopulmonary bypass time was 187 minutes. Weaning from bypass was uneventful, with a low dose of catecholamines. There was no clinically appreciable bleeding from the left ventricular wall. The postoperative course was uneventful, except for peroneal nerve palsy of the right foot (drop foot). Postoperative echocardiography results are shown in Figure 3. There was no marked mitral regurgitation. He was transferred to a local hospital for further rehabilitation on the 22nd postoperative day.
Accepted for publication Sept 18, 2003. Address reprint requests to Dr Yaku, Department of Cardiovascular Surgery, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto 602-8566, Japan; e-mail: [email protected].
© 2004 by The Society of Thoracic Surgeons Published by Elsevier Inc
Comment Rupture of the left ventricle after mitral valve replacement is classified into 3 types [5]. Type I rupture is the 0003-4975/04/$30.00 doi:10.1016/j.athoracsur.2003.09.096
FEATURE ARTICLES
Department of Cardiovascular Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
1852
HOW TO DO IT YAKU ET AL REPAIR OF LV RUPTURE AFTER MVR
Ann Thorac Surg 2004;78:1851–3
FEATURE ARTICLES
Fig 2. Schematic diagram illustrating the partial translocation method for repair of a left ventricular rupture. The tear in the posterior wall of the left ventricle was repaired with mattress sutures buttressed with strips of felt, and the posterior mitral annulus was newly constructed with a crescent-shaped piece of bovine pericardium. A Mosaic bioprosthesis was reimplanted at the native annulus anteriorly and newly constructed annulus posteriorly.
with the internal approach [4]. In addition, although the tear may involve the suture line of the previously placed mitral prosthesis, securing the prosthesis from the exterior of the heart is difficult. The internal method is considered the safest and most successful approach, even though the previously placed prosthesis has to be explanted during cardiopulmonary bypass [4]. Internal repair includes direct closure of the tear with multiple horizontal mattress stitches buttressed with felt [4], patch closure of the tear [2], and covering the tear with a patch sutured on the intact endocardium of the ventricle and the left atrium across the annulus [3]. Fig 1. (A) Nine mattress stitches buttressed with Dacron felt were placed from the intact endocardium of the left ventricle through the deep layer of the muscle and pulled through the mitral annulus. (B) A crescent-shaped piece of bovine pericardium was sutured on the left atrial wall above the repaired mitral annulus. Pledgeted mattress sutures for implantation of a prosthesis were placed through the native annulus anteriorly and the newly constructed annulus posteriorly.
most troublesome because the tear is very close to the atrioventricular groove, making it difficult to close the tear completely without damaging the left circumflex artery and coronary sinus. Several surgical techniques for the repair of left ventricular rupture, including both internal and external approaches, have been described [1– 4]. The external approach is complicated by the fact that the internal disruption site and the external bleeding point are often at different locations; moreover, the circumflex coronary artery is more prone to injury with this approach than
Fig 3. Four-chamber view of echocardiography on the 10th postoperative day. Mitral regurgitation was trivial. (LA ⫽ left atrium; LV ⫽ left ventricle.)
Ann Thorac Surg 2004;78:1851–3
1853
ventricular rupture is a fatal complication, and we consider complete hemostasis at the tear site to be the most important factor at the time of the operation. We have to observe the patient carefully because of the risk of a pseudoaneurysm developing at the repaired site.
References 1. Engelman RM, Rousou JH, Wittenberg SA. New technique for repair of posterior left ventricular rupture. J Thorac Cardiovasc Surg 1979;77:757–9. 2. David TE. Left ventricular rupture after mitral valve replacement: endocardial repair with pericardial patch. J Thorac Cardiovasc Surg 1987;93:935–6. 3. Clemin D, Nunez L, Gil-Aguado M, Larrea JL. Intraventricular patch repair of left ventricular rupture following mitral valve replacement: new technique. Ann Thorac Surg 1982;33: 638 –40. 4. Reardon MJ, Letsou GV, Reardon PR, Baldwin JC. Left ventricular rupture following mitral valve replacement. J Heart Valve Dis 1996;5:10 –5. 5. Treasure RL, Rainer WG, Strevey TE, Sadler TR. Intraoperative left ventricular rupture associated with mitral valve replacement. Chest 1974;66:511–4. 6. Bingley JA, Gardner MAH, Stafford EG, et al. Late complications of tissue glues in aortic surgery. Ann Thorac Surg 2000;69:1764 –8.
FEATURE ARTICLES
There should be some tension at the site where the pledgeted mattress sutures are placed with this technique as compared with the patch exclusion technique. However, because the ventricular muscle where we placed the pledgeted mattress sutures was normal— neither infarcted nor damaged—we were able to close the tear more securely and thereby avoid bleeding from the repaired site. Moreover, because the pledgeted mattress stitches were not transmural to the ventricular muscle, we could avoid injury to the circumflex artery at the atrioventricular groove. We consider avoidance of mechanical stress by the prosthesis on the repaired site crucial to a successful outcome. We therefore constructed a new annulus with bovine pericardium apart from the repaired site and implanted a new prosthesis by using the newly constructed mitral annulus. We call this technique partial translocation of the mitral annulus. With this method, postoperative mitral regurgitation was not considerable, and there was no unexpected bleeding from the repaired site. We used GRF glue at the repaired site in this patient. GRF glue has been reported to subsequently cause some tissue deterioration where it was used [6]. However,
HOW TO DO IT YAKU ET AL REPAIR OF LV RUPTURE AFTER MVR