Should A Flailing Mitral Valve Be Repaired

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Repair Options for Mitral Regurgitation

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Abstruse

Mitral valve repair is the treatment of choice for severe degenerative mitral regurgitation providing meliorate freedom from cardiac events, quality of life and long-term survival compared with mitral valve replacement. Increasing numbers of asymptomatic patients are therefore referred for mitral repair. With refinements of the surgical techniques, long-term results take further improved in the last decade. Certainly experience is crucial in determining the likelihood of success and patients with a mitral valve accounted reparable should exist referred to centers with high volume and extensive experience in this field. In this commodity the current part of mitral valve repair in degenerative mitral regurgitation (MR) will be outlined. Moreover some important concepts regarding indication and techniques of mitral repair in the more challenging setting of secondary (functional) mitral regurgitation volition exist presented and discussed.

Disclosure: The authors have no conflicts of interest to declare.

Received: 01 Feb 2011

Accepted: 27 April 2011

Citation:European Cardiology 2011;vii(2):131–5

Correspondence: Ottavio Alfieri, Section of Cardiac Surgery, San Raffaele University Infirmary, Via Olgettina 60, 20132 Milan, Italy. E: alfieri.ottavio@hsr.it

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Despite the absence of randomised comparison, information technology is widely accepted that, when feasible, valve repair is the optimal surgical handling in patients with severe degenerative mitral regurgitation (MR) due to the well documented advantages of such an approach over valve replacement in terms of perioperative mortality, preservation of postoperative left ventricular (LV) function and long-term survival in this setting.^1,ii Conversely, in patients with secondary (functional) MR, the role of mitral repair is less well established and is still object of debate. In this review we will mainly focus on the bones principles and on the current results of mitral repair in both degenerative and functional MR.

Degenerative Mitral Regurgitation

Degenerative MR represents a rather common pathology, affecting 1–2% of the full general population. In patients requiring surgery for this disease, mitral valve repair is the standard of care. In many patients, the typical sign of the degenerative pathology is an backlog of valve tissue (Barlow's disease), which is the extreme form of myxomatous degeneration. In others, specially in older patients, the valve tissue does non show this alteration but is thinner and translucent (fibroelastic deficiency).

Anatomical and functional alterations that typically characterise degenerative MR are leaflet prolapse into the atrium during systole and annular dilatation. The chordae tendineae tin be thickened or thinned and they can testify elongation or ruptures. The posterior mitral leaflet and afferent chordae tendineae are more than frequently affected past the degenerative process compared with the inductive leaflet.

The most frequent anatomical and pathological amending is elongation or rupture of the chordae tendineae of the posterior leaflet.

Timing for correction of Degenerative Mitral Regurgitation

According to current guidelines, mitral repair is indicated in patients with severe MR who are symptomatic and in those showing initial signs of LV dysfunction (end-systolic bore >40mm, ejection fraction <60%). Surgical treatment is encouraged in asymptomatic patients with preserved LV function when atrial fibrillation occurs or when systolic pulmonary artery pressure is >50mmHg at rest or >60mmHg during exercise. In addition, mitral repair is reasonable for asymptomatic patients with preserved LV function in whom the likelihood of successful repair without remainder MR is >90%.³

However, in the individual patient the controlling regarding the optimal time for surgery may be difficult. Indeed some asymptomatic patients may be candidates for early repair before the occurrence of structural and functional changes in the LV and left atrial chambers, which are predictors of poor post-operative event.^iv Others with advanced age, relevant co-morbidities and/or complex valve lesions may be closely followed in social club to safely postpone surgery (watchful waiting approach).^five

Surgical Techniques of Mitral Repair in Degenerative Mitral Regurgitation

Mitral repair requires greater feel compared with valve replacement and patients with a mitral valve deemed reparable should be referred to centres with a loftier volume and extensive feel in mitral repair. Prior surgical methods associated with suboptimal results such as chordal shortening and the not-employ of an annuloplasty ring have been recognised⁶ with benign effects on the evolution of mitral valve reconstructive surgery. Moreover new technical solutions have been added to the central methods of repair commencement described by Carpentier, including the utilise of artificial chordae made of expanded polytetrafluoroethylene⁷ and the edge-to-edge (East-to-Due east) technique.⁸ Therefore, nowadays >ninety% of degenerative lesions tin can be repaired successfully in skillful centres past use of contemporary techniques.

From a technical point of view, valve repair for degenerative MR includes a large assortment of valvular, subvalvular and annular procedures whose choice depends on the lesions identified during the preoperative echocardiograms and the intraoperative surgical examination of the mitral apparatus.

Posterior Leaflet Prolapse

In patients with isolated prolapse of the middle scallop (P2) of the posterior leaflet, which is encountered in the majority of patients with degenerative mitral regurgitation, repair usually involves quadrangular resection of this scallop. Annulus folding is performed at the implantation base of the resected segment and the remaining portions (P1 and P3) of the posterior leaflet are then brought together and sutured directly without exerting excessive tension on them. In this fashion the continuity of the posterior leaflet is restored. Nowadays, in many institutions, annular plication tends to be avoided by using techniques such as the sliding plasty or the folding plasty, which are indicated when the valve tissue is too redundant in order to decrease the chance of mail service-operative dynamic obstruction to the LV outflow tract.

This complication (systolic inductive motion, SAM) occurs in 5–10% of MR cases treated by simple quadrangular resection. The best strategy to avoid it is to reduce the pinnacle of the posterior leaflet to <15mm so that the coaptation point of the two valve leaflets can exist moved posteriorly. Indeed, a sliding plasty or a folding plasty can be used for this purpose. In the sliding plasty after quadrangular resection the height of the posterior leaflet is reduced by incisions in the basal portions of P1 and P3, followed by reapproximation of the free edges. In the folding plasty, subsequently resection of the prolapsing segment, the edge of the residual cut leaflet is folded (or rotated) toward the annulus and reattached to it. Continuity of the posterior leaflet is then restored past suturing together the remaining portions.

In cases of posterior leaflet prolapse without redundant leaflet tissue, express resection or artificial chordal replacement with Gore-Tex expanded polytetrafluoroethylene sutures may be appropriate. In item, in some institutions, the use of neochordae to correct severe degenerative MR due to posterior leaflet prolapse, has been progressively preferred to the standard resection approach (the so chosen 'respect rather and then resect' approach). The neochordae are sutured to the gristly portion of the papillary muscle and and then to the gratis margin of the prolapsing portion of the posterior leaflet and the repair is completed by a band annuloplasty.

Inductive Leaflet Prolapse

Repairs of the anterior leaflet, either in isolation or with concomitant posterior leaflet repair, are more circuitous procedures than repair of posterior leaflet prolapse solitary. Various techniques may be used, including limited triangular resection of the anterior leaflet, chordal transposition, papillary muscle repositioning, artificial chordal replacement and the E-to-E repair.

Triangular Resection

A limited prolapse of the anterior leaflet tin be easily treated by triangular resection of the prolapsing segment, followed by direct suture of the remaining leaflet portions. Resection should never involve an surface area greater than 10% of the total area of the inductive leaflet every bit it may otherwise distort the beefcake reducing the coaptation surface and impairing its mobility. When correctly practical the results of this technique are similar to those of the other repair procedures adopted for anterior leaflet prolapse.

Chordal Transposition

I of the techniques that has been most widely used to right anterior leaflet prolapse is chordal transposition. This technique consists of detaching a secondary chorda, with an adequate length and construction, from its implantation point on the ventricular side of the anterior leaflet and reimplanting it on the gratuitous margin of the same leaflet nearly the prolapsing segment.

Alternatively, marginal chordae of the segment of the posterior leaflet located in forepart of the prolapsing one tin exist used. In this case a segment of the posterior leaflet with the respective chordae is detached and then reattached using a 4.0 prolene suture on the free margin of the prolapsing segment of the anterior leaflet (the 'flip-over' technique). The defect on the posterior leaflet is and then sutured in the same way as a standard quadrangular resection. The reward of chordal transposition compared to the use of artificial chordae is that the former already have the correct length, while the major claiming for a surgeon when using the latter is to make up one's mind the right length. One of the main disadvantages of the flip-over approach is the fact that a valve segment non affected past the pathology needs to exist resected in order to transpose the chordae tendineae of the posterior leaflet.

Papillary Muscle Repositioning

Papillary muscle repositioning has been conveniently used to correct inductive and bi-leaflet prolapse due to chordal elongation especially in the difficult setting of global mixomatous degeneration of the mitral valve (Barlow'due south disease). This technique consists in separating the anterior head of the papillary muscle from the other heads and taking it downwardly into the left ventricle. This is accomplished by putting a stitch in the gristly segment of the anterior head and tying it to the gristly segment of the posterior caput. Since the chordae arising from the anterior head are anchored to the anterior leaflet, by shortening its length it is possible to right anterior leaflet prolapse.

Implantation of Bogus Chordae

The utilise of artificial chordae tendineae (neochordae) is probably the almost widely used technique to treat anterior leaflet prolapse, and many groups take documented splendid results with this approach. When using this technique it is essential to comply with the normal anatomy of the mitral subvalvular apparatus and the physiological distribution of the chordae tendineae: those arising from the inductive papillary muscle are distributed in the lateral half of the anterior and posterior leaflets, while those originating from the posterior papillary muscle anchor the median half.

The textile most commonly used in surgical practise are iv.0 or 5.0 polytetrafluoroethylene (PTFE) neochordae (suture Gore-Tex, WL Gore & Associates, Flagstaff, AZ, US). Artificial chordae are attached to the fibrous portion of the papillary musculus on one terminate and to the free margin of the prolapsing portion of the anterior leaflet on the other. Several artificial chordae are unremarkably needed depending on the extension of the prolapsing segment. The main technical difficulty lies in determining the proper length of the neochordae. In case of isolated prolapse of the anterior leaflet, the best way to determine the right length is to use the top of the non-prolapsing posterior leaflet as a reference. In the case of b-ileaflet prolapse or prolapse of several segments, the signal of reference to exist used is the lateral commissure, unless it is afflicted by the degenerative procedure. Modified artificial chordae with a premeasured loop have recently been introduced to facilitate the choice of the proper length. When using neochordae it should exist considered that in the case of a very dilated left ventricle in that location is a higher adventure of relapse of prolapse some time subsequently surgery, due to the occurrence of contrary LV remodelling, which tin can make the length of the neochorda become too long.

Edge-to-border Technique

The E-to-East technique is another method of mitral valve repair that has been introduced in the armamentarium of mitral valve repair in the early nineties as a elementary method to conveniently correct MR in presence of some complex lesions.^nine,10 The idea behind the E-to-Eastward approach is that the competence of a regurgitant mitral valve can be effectively restored with a 'functional' rather than an 'anatomical' repair. The key point is to place the location of the regurgitant jet. Exactly at that signal, the gratuitous edge of one leaflet is sutured to the corresponding edge of the opposing leaflet, thereby eliminating the incompetence of the mitral valve. When the regurgitant jet is in the central office of the valve, the E-to-E repair produces a mitral valve with a double orifice configuration. Depending on the location of the suture, the 2 orifices can have like or different sizes. When the regurgitant jet is located in the proximity of a commissure, the E-to-Due east procedure leads to a single orifice mitral valve with a relatively smaller area. The technique appeared to be bonny considering of its simplicity, reproducibility and effectiveness even in complex settings. Several institutions around the world adopted the E-to-E technique in selected patients with MR due to dissimilar aetiologies and mechanisms.^11–xiv

A 4-0 polypropylene continuous mattress suture is passed first, followed by an over-and-over continuous suture with the same 4-0 polypropylene. A flexible or semi-rigid prosthetic ring is almost invariably implanted to increase the coaptation surface of the leaflets, reduce the stress on the East-to-E suture and stabilise the repair. The global mitral valve area is assessed by direct inspection and, in example of doubt, past introducing Hegar dilators into the valve orifices. In normal size patients merely a global valve area of more than 2.5cm2 is accepted. Transoesophageal repeat-doppler performed later on weaning from cardiopulmonary bypass typically shows no rest MR and two diastolic flows through the double orifice mitral valve. The valve area is commonly assessed by a planimetric method using the trans-gastric short-axis view. Using the Eastward-to-E technique, fifty-fifty circuitous mitral valves can exist currently repaired with a very brusque cross-clamp fourth dimension. The technique is very versatile and it has been used with very satisfactory results in patients with segmental prolapse of the anterior leaflet,¹⁵ commissural prolapse^16,17 and bi-leaflet prolapse of facing segments in the context of a global mixomatous degeneration of the mitral valve (Barlow's disease). In this concluding setting both leaflets are prolapsing, due to chordal elongation or rupture. When the prolapse is involving facing segments (more ordinarily A2 and P2), the E-to-Due east technique tin be conveniently applied.¹⁸ The Eastward-to-E technique can be a useful adjunct to the undersized annuloplasty to care for functional mitral regurgitation in patients with dilated cardiomyopathy as it volition exist outlined later in this article. Finally, information technology has also been used as a 'rescue' procedure in patients with pregnant residual MR after conventional mitral repair and to prevent or treat SAM.

Mitral Annuloplasty

Remodelling of the mitral annulus by means of annuloplasty is ane of the key concepts in mitral repair surgery. Annular dilatation is almost always present in patients with degenerative MR, typically involving the posterior annulus since the anterior portion is anchored to the heart'south gristly skeleton. Besides annular dilatation, in degenerative MR there is also an alteration in the shape of the annulus leading to a reduced leaflet coaptation. The aim of annuloplasty is to restore normal annulus dimensions and shape, to foreclose farther dilatation and to increase the coaptation surface of the leaflets leading to increased mitral repair immovability. Therefore, all the previously described surgical techniques should exist followed past a ring annuloplasty.

The final repair is assessed initially by visual inspection and by injecting saline through the mitral valve to look for regurgitation (the 'saline test'), and so by intraoperative transoesophageal echocardiography afterwards the patient is weaned from cardiopulmonary bypass. Patients should not leave the operating theatre with more i+ mitral regurgitation on transesophageal echocardiography.

Results

Hospital mortality after isolated mitral repair for degenerative MR in high-volume centres¹⁹ is <i%.^xx If the process is performed before the onset of symptoms and LV dysfunction, patient survival and quality of life after the process perfectly matches that of the general population of the aforementioned historic period.^21,22 By contrast, patient survival is reduced if the procedure is carried out in patients with symptoms of congestive middle failure and in presence of reduced LV ejection fraction (LVEF).²¹

Mitral valve repair failure rates, defined by recurrence of moderate or severe mitral regurgitation or re-operation for mitral regurgitation, are determined by the aetiology, lesion and repair techniques. Most early failures are the result of technical issues, and the presence of residual mitral regurgitation greater than mild immediately after surgery is a strong predictor of this event. Late failures primarily relate to progression of the degenerative disease with the occurrence of new leaflet prolapse/flail and, less normally, leaflet retraction or infection.

Contempo studies take documented a take a chance of recurrence of moderate or severe mitral regurgitation afterward repair of i–2% per year, particularly in patients with anterior or bi-leaflet prolapse, which are technically more difficult to treat.^23,24 Indeed, in most of the published series, the best results have been obtained in patients with isolated prolapse of the posterior leaflet treated with quadrangular resection associated with annuloplasty with a freedom from reoperation at twenty years of 97%. On the other manus, less favourable outcomes take been consistently and repeatedly reported in patients with MR due to inductive leaflet and bi-leaflet prolapse.^25–27 However, particularly in the last decade, after the introduction in the surgical armamentarium of the artificial chordae and of the edge-to-edge technique, several groups have reported comparable long-term results in patients with posterior, anterior and bi-leaflet prolapse,^15,28 and information technology is likely that, with continued refinement of mitral repair strategies, anterior and bi-leaflet prolapse will be completely neutralised as incremental adventure factors for recurrent MR after repair.

Mitral Valve Repair for Functional Mitral Regurgitation

Functional MR results from changes in LV geometry leading to papillary musculus dislocation and consequent tethering of the leaflets.

Almost invariably the annulus is dilated and deformed, while the valve leaflets are morphologically normal.²⁹ While valve repair for degenerative MR includes the large assortment of valvular, subvalvular and annular procedures previously described, surgical correction of functional MR in patients with ischaemic or non-ischaemic dilated cardiomyopathy, is mainly performed past means of a restrictive (undersized) annuloplasty aiming at reduction and reshaping of the annulus to eliminate the insufficiency of the valve.^thirty–32

In the opinion of the majority of the surgeons the appropriate prosthetic ring in this clinical context should be complete and rigid.^33,34 and at least ii sizes under the 1 measured following the standard criteria^35,36 in order to obtain a leaflet coaptation length of at least 8mm. The procedure is simple and easily reproducible. In appropriately selected patients a well performed restrictive annuloplasty is associated with a low operative mortality and is effective in eliminating MR, promoting LV opposite remodelling, reducing symptoms and improving quality of life. However, when the patient selection criteria are non respected, residual/recurrent MR can often occur, and such an event is strictly related with an unfavourable outcome in terms of heart failure and mortality in the follow-up.^37,38 Patient selection for annuloplasty is therefore crucial. Indeed balance or recurrent valve insufficiency following mitral annuloplasty is probable in presence of preoperative complex/multiple regurgitant jets,³⁹ severe tethering of the leaflets (coaptation depth >1.5cm), an angle between the posterior mitral leaflet and the annular airplane in systole >45°,^forty significant distal inductive mitral leaflet tethering (angle between the annular airplane and a line that joins the anterior annulus and the coaptation point >25°).⁴¹ The result of annuloplasty lonely is especially unfavourable in the rare instances where severe leaflet tethering is associated with but mild annular dilatation since, in these circumstances, an constructive reduction of the size of the mitral annulus is unlikely to be surgically obtained owing to the lack of pregnant preoperative dilatation. Moreover, the clinical history has a relevant role in selecting patients for annuloplasty.

It has been clearly documented that reverse remodelling following annuloplasty occurs much more frequently in patients with a brusque elapsing of symptoms of heart failure and a smaller pre-operative LV size.^35,42 Therefore, undersized annuloplasty alone should just be carried out in the early phase of the disease, when the history of center failure is short, the left ventricle is not excessively dilated and the well divers echocardiographic predictors of recurrence of MR after repair are absent-minded.

Under certain circumstances other surgical procedures can be conveniently added to restrictive annuloplasty to enhance the effectiveness and immovability of repair. Resection of the secondary chordae of the anterior leaflet,⁴³ repositioning of the tip or the base of the papillary muscles,^44–46 the addition of the edge-to-edge suture,⁴⁷ the clan of an external cardiac support⁴⁸ and a concomitant LV restoration⁴⁹ procedure have demonstrated a positive effect on the immovability of annuloplasty in well-selected patients. Finally, when an constructive and durable mitral valve repair is not expected attributable to advanced LV remodelling and long-lasting heart failure, valve replacement with a bioprosthesis, preserving the integrity of the subvalvular appliance, tin can exist a reasonable alternative.

Electric current guidelines practise non recommend correction of functional MR in patients with dilated cardiomyopathy if concomitant coronary revascularisation is not required.^50,51 Suboptimal information regarding the postoperative result explain uncertainties in surgical indications. In addition, the absence of randomised trials showing the benefit of surgery over medical treatment is also a strong argument against recommending surgery. However, despite all of the above, correction of functional MR is by and large advocated^52,53 because the improvements in symptoms and quality of life later on surgery are a major reward of surgical treatment in patients who are usually experiencing repeated hospital admissions for congestive heart failure despite maximal medical therapy. Obviously, due to the clinical profile of these patients, a careful evaluation of the surgical risk versus the benefit of the operation is mandatory in the private patient and definite surgical contraindications have to be identified. Heavy co-morbidities, astringent right ventricular dysfunction and/or extreme LV dysfunction without contractile reserve nether dobutamine infusion during echocardiography are absolute contraindications to surgery.

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Source: https://www.ecrjournal.com/articles/repair-options-mitral-regurgitation

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