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Posterior tricuspid leaflet and chordae for mitral valve repair
22nd World Congress of the International Society for Cardiovascular Surgery 1
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Comparative Study of Kay-Boyd's and Carpentier's Annuloplasty in the Management of Functional Tricuspid Regurgitation: L o n g - T e r m Follow-up K. ONODA~ I. HIOKI, B. PAGOADA, J. TANAKA, T. KOMADA, T. MIZUMOTO, M. TAKAO, H. SHIMPO, K. TANAKA, H. YUASA and I. YADA, Tsu, Mie, Japan The management of tricuspid regurgitation (TR) associated with disease of the mitral or aortic valve, or both, remains controversial. We have already reported that Kay-Boyd annuloplasty is acceptable for localized TR, whereas the Carpentier Edward's ring annuloplasty should be used for massive TR. The classification of TR is based on the direction and area of regurgitation flow on Doppler echocardiogram (J Cardiovasc Surg 1990; 31: 771-777). The ability of these two methods to control regurgitation (TR graded 1 or 11) in cases with residual pulmonary hypertension (PH) was studied on a long-term basis. From February 1980 to January 1994, 68 patients with such a functional TR had Kay-Boyd tricuspid annuloplasty, and 41 patients received Carpentier's tricuspid annuioplasty in our institute. In 53 patients with PH (mean pulmonary arterial pressure [mPAP]: over 30 mmHg) on a pre-operative cardiac catheterization, 29 patients underwent the Kay-Boyd method and 24 the C-E method. In those patients whose mPAP decreased to less than 30 mmHg on a post-operative catheterization, the rate of control regurgitation was 93.3% in the Kay-Boyd group and 100% in the C-E group. On the other hand, in the cases with residual PH, the rate of control regurgitation was 35.7% (five patients) in the Kay-Boyd group and 88.9% (eight patients) in the C-E group. In six of nine patients with the uncontrolled TR (TR graded Ill or IV) in the Kay-Boyd group, the main cause of the TR was the deterioration of the residual disease of the mitral or aortic valve. However, in two patients with paravalvular leakage of mitral prosthesis in the C-E group, TR was well controlled. Only one patient needed refixation of C-E ring due to rupture of the sutured thread. We conclude that although the Kay-Boyd method is acceptable for localized TR, the C-E method is effective for massive TR and the control of TR with residual PH. 19.5
Long-term Results of Mitral Valvuloplasty for Mitrai Valve Regurgitation Due to Rheumatic Valvulitis K. TANO, K. EISHI, J. KOBA YASHI, Y. SASAKO, S. NAKANO, F. ISOBE, Y. KOSAKAI, Y. KITOH and Y. KAWASHIMA, Osaka, Japan Mitral valvuloplasty (MP) has become the main procedure for the treatment of mitral regurgitation (MR). Progression of the sclerotic changes in mitral valves was, however, halted in the rheumatic valve. From January 1978 to September 1993, 76 MPs were performed in patients with rheumatic valvulitis. Ages ranged from 25 to 74 years (mean age, 48 years), and mean follow-up interval was 7.6 years (range, 0 month to 16 years). Early mortality was 3.9%, and there were 10 late deaths (including two operative deaths at reoperation). Twenty-one patients (27.6%) required reoperations. Reoperation-free ratio was 84.7% at 5 years, 77% at 10 years and 52.8% at 15 years. The causes of reoperation were
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significant MR (>-3/4) in all patients, combined with mitral stenosis (MS; pressure gradient through the mitral valve -> 5 mmHg) in 52.4% by Doppler echocardiography. Moreover, 85.7% of these MR cases had been detected immediately after the initial operation. Reoperations were required in 47.1% of the patients who had had residual MR following MP, and in 8.8% of the patients without residual MR (P = 0.003). There was no significant difference in the incidence of reoperation between the patients with residual MS (16.7%) and the patients without MS (10.5%). Reoperations were performed in 9.3% of the patients without residual MR or MS. In conclusion, a reoperation (because of the progression of residual MR and valve sclerosis) free rate following MP for the rheumatic vaivulitis was remarkably decreased after 10 years from operation. The most important factor for long durability is to control MR completely at the initial valvuloplasty. 19.6
Posterior Tricuspid Leaflet and Chordae for Mitral Valve Repair U. HVASS, D. CHA TEL, P. ASSA YA G, J. CALIANI, and Y. PANSARD, Paris, France OBJECTIVE: Some mitral lesions are still out-of-reach of conventional repairs. Transferring the posterior leaflet of the tricuspid valve with its subvalvular apparatus to the mitral valve is a new technique that has allowed us a conservative approach in cases where the results of repair seemed less predictable. METHODS: After removing the posterior tricuspid leaflet with its subvalvular apparatus, the tricuspid autograft was inserted by implanting its papillary muscle onto the mitral papillary muscle and then by suturing in place of the leaflet tissue. The tricuspid valve was subsequently repaired by annular plication and leaflet suture. A prosthetic tricuspid annulus was used in all but the first case. RESULTS: The five patients ages ranged from 22-70 years old. Post-operative controls by transesophageal echocardiography showed no leaks in five and a trivial leak in one at the site of mitral repair. On the tricuspid valve, we found a moderate leak in the first case and trivial or none in the following cases where a prosthetic annulus was used. With a 2-12 month follow-up, the results are stable. CONCLUSION: This autograft technique is reproducible, and extends the field of mitral repairs. Opposed to segments of mitral homografts is the intra-operative availability of natural chordae and valvular leaflets that have no immunological interferences. The patient is his own tissue bank, and the tricuspid valve can be repaired with a very low risk of significant dysfunction. 19.7
Ring Annuloplasty Versus Suture Annuloplasty in Repair of Mitral Valve Disease. A Comparative Study N.R.H. RASMI, and H. M. GAAFAR, Cairo, Egypt Between July 1992 and October 1994, 364 patients underwent mitral valve surgery (224 replacement and 140 repair). Valve repair was achieved by using different flexible and semiflexible rings in 65 patients (46.6%) and commisural suture annuloplasty in 75 patients (53.4%), in addition to other valve
CARDIOVASCULAR SURGERY SEPTEMBER 1995
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Comparative Study of Kay-Boyd's and Carpentier's Annuloplasty in the Management of Functional Tricuspid Regurgitation: L o n g - T e r m Follow-up K. ONODA~ I. HIOKI, B. PAGOADA, J. TANAKA, T. KOMADA, T. MIZUMOTO, M. TAKAO, H. SHIMPO, K. TANAKA, H. YUASA and I. YADA, Tsu, Mie, Japan The management of tricuspid regurgitation (TR) associated with disease of the mitral or aortic valve, or both, remains controversial. We have already reported that Kay-Boyd annuloplasty is acceptable for localized TR, whereas the Carpentier Edward's ring annuloplasty should be used for massive TR. The classification of TR is based on the direction and area of regurgitation flow on Doppler echocardiogram (J Cardiovasc Surg 1990; 31: 771-777). The ability of these two methods to control regurgitation (TR graded 1 or 11) in cases with residual pulmonary hypertension (PH) was studied on a long-term basis. From February 1980 to January 1994, 68 patients with such a functional TR had Kay-Boyd tricuspid annuloplasty, and 41 patients received Carpentier's tricuspid annuioplasty in our institute. In 53 patients with PH (mean pulmonary arterial pressure [mPAP]: over 30 mmHg) on a pre-operative cardiac catheterization, 29 patients underwent the Kay-Boyd method and 24 the C-E method. In those patients whose mPAP decreased to less than 30 mmHg on a post-operative catheterization, the rate of control regurgitation was 93.3% in the Kay-Boyd group and 100% in the C-E group. On the other hand, in the cases with residual PH, the rate of control regurgitation was 35.7% (five patients) in the Kay-Boyd group and 88.9% (eight patients) in the C-E group. In six of nine patients with the uncontrolled TR (TR graded Ill or IV) in the Kay-Boyd group, the main cause of the TR was the deterioration of the residual disease of the mitral or aortic valve. However, in two patients with paravalvular leakage of mitral prosthesis in the C-E group, TR was well controlled. Only one patient needed refixation of C-E ring due to rupture of the sutured thread. We conclude that although the Kay-Boyd method is acceptable for localized TR, the C-E method is effective for massive TR and the control of TR with residual PH. 19.5
Long-term Results of Mitral Valvuloplasty for Mitrai Valve Regurgitation Due to Rheumatic Valvulitis K. TANO, K. EISHI, J. KOBA YASHI, Y. SASAKO, S. NAKANO, F. ISOBE, Y. KOSAKAI, Y. KITOH and Y. KAWASHIMA, Osaka, Japan Mitral valvuloplasty (MP) has become the main procedure for the treatment of mitral regurgitation (MR). Progression of the sclerotic changes in mitral valves was, however, halted in the rheumatic valve. From January 1978 to September 1993, 76 MPs were performed in patients with rheumatic valvulitis. Ages ranged from 25 to 74 years (mean age, 48 years), and mean follow-up interval was 7.6 years (range, 0 month to 16 years). Early mortality was 3.9%, and there were 10 late deaths (including two operative deaths at reoperation). Twenty-one patients (27.6%) required reoperations. Reoperation-free ratio was 84.7% at 5 years, 77% at 10 years and 52.8% at 15 years. The causes of reoperation were
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significant MR (>-3/4) in all patients, combined with mitral stenosis (MS; pressure gradient through the mitral valve -> 5 mmHg) in 52.4% by Doppler echocardiography. Moreover, 85.7% of these MR cases had been detected immediately after the initial operation. Reoperations were required in 47.1% of the patients who had had residual MR following MP, and in 8.8% of the patients without residual MR (P = 0.003). There was no significant difference in the incidence of reoperation between the patients with residual MS (16.7%) and the patients without MS (10.5%). Reoperations were performed in 9.3% of the patients without residual MR or MS. In conclusion, a reoperation (because of the progression of residual MR and valve sclerosis) free rate following MP for the rheumatic vaivulitis was remarkably decreased after 10 years from operation. The most important factor for long durability is to control MR completely at the initial valvuloplasty. 19.6
Posterior Tricuspid Leaflet and Chordae for Mitral Valve Repair U. HVASS, D. CHA TEL, P. ASSA YA G, J. CALIANI, and Y. PANSARD, Paris, France OBJECTIVE: Some mitral lesions are still out-of-reach of conventional repairs. Transferring the posterior leaflet of the tricuspid valve with its subvalvular apparatus to the mitral valve is a new technique that has allowed us a conservative approach in cases where the results of repair seemed less predictable. METHODS: After removing the posterior tricuspid leaflet with its subvalvular apparatus, the tricuspid autograft was inserted by implanting its papillary muscle onto the mitral papillary muscle and then by suturing in place of the leaflet tissue. The tricuspid valve was subsequently repaired by annular plication and leaflet suture. A prosthetic tricuspid annulus was used in all but the first case. RESULTS: The five patients ages ranged from 22-70 years old. Post-operative controls by transesophageal echocardiography showed no leaks in five and a trivial leak in one at the site of mitral repair. On the tricuspid valve, we found a moderate leak in the first case and trivial or none in the following cases where a prosthetic annulus was used. With a 2-12 month follow-up, the results are stable. CONCLUSION: This autograft technique is reproducible, and extends the field of mitral repairs. Opposed to segments of mitral homografts is the intra-operative availability of natural chordae and valvular leaflets that have no immunological interferences. The patient is his own tissue bank, and the tricuspid valve can be repaired with a very low risk of significant dysfunction. 19.7
Ring Annuloplasty Versus Suture Annuloplasty in Repair of Mitral Valve Disease. A Comparative Study N.R.H. RASMI, and H. M. GAAFAR, Cairo, Egypt Between July 1992 and October 1994, 364 patients underwent mitral valve surgery (224 replacement and 140 repair). Valve repair was achieved by using different flexible and semiflexible rings in 65 patients (46.6%) and commisural suture annuloplasty in 75 patients (53.4%), in addition to other valve
CARDIOVASCULAR SURGERY SEPTEMBER 1995