Mitral valve repair and related aspects

Dr Dheeraj sharma
M.Ch (CTVS) Resident

 Sir Thomas Lauder Brunton, a Scottish physician, first
introduced the concept of surgical repair of the mitral
valve in 1902.
 Elliot Cutler ,Professor of Surgery at the Peter Bent
Brigham Hospital in Boston, performed the world’s
first successful mitral valve operation in 1923 by
carrying out a transventricular commissurotomy with
a neurosurgical tenotomy knife.
 Henry Souttar of England performed a single
successful transatrial finger commissurotomy in 1925.
 Surgical treatment of mitral regurgitation for prolapse
was first introduced in the 1950s.

 Harold and kay obliterated the commisures using
sequence of mattress sutures.
 Paneth and devega did the annuloplasty by taking
the circumferential sutures around the annulus.
 In 1960 McGoon proposed the resection of part of
leaflets with ruptured chordae as a part of repair.
 Carpentier and Duran started the use of
prosthetic rings to remodel the mitral valve
annulus.

Organic
• Degenerative
• Barlow’s
• Dystrophic
• Marfan’s
• Other
• Endocarditis
• Rheumatic
• Post-traumatic
Functional
• Ischemic
• DCM

RECOMMENDATION COR LOE
MV surgery is recommended for symptomatic patients with
I B
chronic severe primary MR (stage D) and LVEF >30%
MV surgery is recommended for asymptomatic patients with
chronic severe primary MR and LV dysfunction (LVEF 30%–
60% and/or LVESD ≥40 mm, stage C2)
I B
MV repair is recommended in preference to MVR when
surgical treatment is indicated for patients with chronic severe
primary MR limited to the posterior leaflet
I B
MV repair is recommended in preference to MVR when
surgical treatment is indicated for patients with chronic severe
primary MR involving the anterior leaflet or both leaflets when
a successful and durable repair can be accomplished
I B
Concomitant MV repair or replacement is indicated in patients
with chronic severe primary MR undergoing cardiac surgery
for other indications .
I B

MV repair is reasonable in asymptomatic patients with chronic severe
primary MR (stage C1) with preserved LV function (LVEF >60% and
LVESD <40 mm) in whom the likelihood of a successful and durable repair
without residual MR is >95% with an expected mortality rate of
<1% when performed at a Heart Valve Center of Excellence
IIA B
MV repair is reasonable for asymptomatic patients with chronic severe
nonrheumatic primary MR (stage C1) and preserved LV function in whom
there is a high likelihood of a successful and durable repair with 1) new onset
of AF or 2) resting pulmonary hypertension (PA systolic arterial pressure >50
mm Hg)
IIA B
Concomitant MV repair is reasonable in patients with chronic moderate
primary MR (stage B) undergoing cardiac surgery for other indications
IIA C
MV surgery may be considered in symptomatic patients with chronic severe
primary MR and LVEF 30% (stage D)
IIB C
MV repair may be considered in patients with rheumatic mitral valve disease
when surgical treatment is indicated if a durable and successful repair is
likely or if the reliability of long-term anticoagulation management is
questionable
IIB B
Transcatheter MV repair may be considered for severely symptomatic
patients (NYHA class III/IV) with chronic severe primary MR (stage D) who
have a reasonable life expectancy but a prohibitive surgical risk because of
severe comorbidities
IIB B
MVR should not be performed for treatment of isolated severe primary MR
limited to less than one half of the posterior leaflet unless MV repair has been
attempted and was unsuccessful
III B

 1. mitral valve replacement.
 2. mitral valve repair

• Better preservation of LV function
• Avoidance of prosthesis related events(hazards of
anticoagulation, stroke, endocarditis, short life
span of bioprosthesis, poor patient compliance)
• Reduced hospital mortality
• Reduced morbidity and LOS
• Improved long term survival
Thourani et al, Circulation 2003; 108:298-304
Zaho et al, JTCVS 2007;1257-1263
Shuhaiber J et al, EJCTS 2007; 31:267-275
Perrier P et al, Circulation 1984;70:187
Akins CW, et al. ATS 1994; 58:668-676

 1. create apposition of anterior and posterior
leaflet in systole.
 2. increase the valve mobility
 3. prevent valve stenosis
 4. reduce the annular dilatation
 5. remodel the annulus
 6. remove all the infective foci in case of
endocarditis.

 Myxomatous mitral valve disease is most
common indication of mitral valve surgery .
 90% of the mitral valves are amneble to
surgical repair.
 Features of myxomatous mitral valve:
1. Dilated annulus
2. Elongated redundant leaflets
3. Chordae may be thin or thick, ruptured or
elongated

 Symptomatic patients with mitral valve disease
and 3+ and 4+ regurgitation.
 Asymptomatic patients with 3+ or 4+
regurgitation and evidence of decreased LV
function demonstrated by LV dilatation and
decreased EF and new onset atrial fibrillation.

 Principles of repair includes:
1. Apposition of anterior and posterior leaflet in
systole.
2. Reducing the height of posterior leaflet(most
critical step).
3. Stabilizing the AML (by repair or replacement
of chordae).
4. Remodelling the annulus by prosthetic ring.

 In case of the myxomatous mitral valve disease
in around 80% of cases it is the PML which is
involved (especially p2) and in 20% cases
pathology involves AML.
 if we deal with the PML and annulus
effectively ,AML can be left intact . Repair of
AML is required in specific situations.

 Quadrangular
resection
 Sliding plasty(leaflet
advancement
technique)
 Chordal replacement
 Anterior leaflet
commissuroplasty
 Folding plasty

 This technique is used when posterior leaflet is
markedly elongated specifically P2 sgment.
 Here we perform a limited resection of the
involved segment removing minimal number
of adjascent chordae and much of the
supporting structures. This effectively reduce
the height of PML.
 The area is excised in trapezoid or
quadrangular shape with narrowest portion of
trapezoid at the annulus.

 After resection the remaining parts of the
leaflet are brought together by suturing the
leaflet to annulus and to each other directly.
 First the two annular stitches are brought
together by running sutures followed by
approximating the leaflet parts from tip to
annulus.
 Disadvantage:
1. Distortion of annulus if the involved segment is
large.

 With this technique one incorporates excess
tissue from remaining segments of posterior
leaflet, bringing the remaining segments
together and at same time preserving as many
chordae .
 Here after quadrangular resection the incision
given along the annulus in remaining leaflet
tissue upto both the commissure followed by
gradual reattachmentof leaflet to annulus by
advancing the remaining leaflet in space
vacated by resected tissue.

 This technique allows remodeling of tissue
which can be easily adjusted to residual tissue
and height of leaflet.
 Pledgeted sutures are not used as they cause
scarring and provide a site for potential
thrombus formation.
 Running sutures along the annulus margin are
important as they help to reduce the height of
posterior leaflet.
 Any annular distortion is taken care by
annuloplasty ring.

 Placing annuloplasty ring is final step of basic
mitral valve repair.
 Most important aspect of ring selection is to
find exact size and shape .
 To exactly size the ring there are two methods:
1. Intertrigonal distance
2. The height of anterior leaflet.

 To mark the two trigones we first place U
stitches at the two trigones . These stitches help
to stabilize the intertrigonal area for exact
sizing.
 Rings can be implanted by running sutures but
most commonly deep intraventricular annular
mattress sutures are placed.
 9-11 sutures are usually sufficient to
completely encircle even the most dilated
valves.

 For myxomatous mitral valve disease it is
better to upsize the ring rather than
downsizing so as to minimizing the possibility
of development of SAM.

 This technique is used when the commissural
part of the posterior leaflet is prolapsed .
 Here we take a suture from diseased segment
of posterior leaflet and pass it through the
normal opposite leaflet tissue and tying the
knot on the surface of leaflet thus obliterating
the prolapsed segment.

 Chordal replacement
 Alfieri / E2E
 Chordal transfer
 Papillary muscle
repositioning
 Triangular resection
 Flip over technique
 Durans technique

 Also known as artificial chordal implantation.
 Technique:
This technique involves placing a mattress suture
with a pledget on the papillary muscle to which
the redundant or ruptured chord has
beenattached. The two ends of the double-armed
PTFE are the brought up through the edge of the
leaflet that needs to be lowered. The critical part of
this technique is determining the degree to which
the leaflet is lowered and hence how tightly the
stitch is tied down.

 Artificial chordae with PTFE is the technique
that is perhaps the most popular current
technique for AML pathology.
 Originally described by Frater and Zussa.
 Duran has devised a method for more precise
measurement of the correct height for these
new chordal structures.

Gillinov, JTCVS 2008
DISADVANTAGES
 Difficult sizing
ADVANTAGES
 Anatomical
reconstruction
 No resection needed

 Also known as alfereri
technique.
 First case performed in
1991
 Technically simple and
reproducible

 Indication:
1. Compromised LV with very less EF.
2. Ruptured anterior leaflet.
3. Hemodynamic compromised patient where
urgent intervention is required . Where we
cannot prolong the pump time. This procedure
serves as bailout procedure.

 Technique: it is simple , we approximate
anterior and posterior leaflets at same level to
create a figure of 8 mitral valve orifice.
 Disadvantage: there are chances of mitral valve
stenosis. To ensure the adequacy of each orifice
created by the edge-to-edge technique, we also
measure the diameter of each orifice and
confirm that it is at least 2 cm in diameter.
 If the orifices are less than 2 cm in diameter,
the technique is abandoned.

 When employed to correct the anterior leaflet
prolapse , a suture affixes the free edge of a
segment of normal posterior leaflet to free edge
of prolapsing segment of anterior leaflet.
 The nomal posterior leaflet with its intact
chordae serves to anchor the anterior leaflet
and restricts its motion.

 Also known as chordal shortening and is
originally described by Carpentier for leaflet
prolapse due to elongated chordae .
 The elongated chordae are burried in the trench
of papillary muscle to effectively reduce the
size of chordae and thus reducing the prolapse
of leaflet.
 Disadvantage: there are high chances of
recurrence. The scissoring motion of papillary
muscle causing erosion and rupture.

 One of the first techniques developed by
Carpentier of chordal shortening involves
incising the papillary muscle, placing the
redundant anterior leaflet chords within the
muscle, and then sewing the papillary muscle
over the chord, thus entrapping the chordae
and shortening it.

 In this technique we cut the healthy leaflet
segment from posterior leaflet with attached
chordae just opposite to the involved anterior
leaflet segment and implant this healthy
segment on diseased leaflet segment.
 The advantage is that it is not necessary to
precisely measure the chordal length as natural
chordae are of adequate length.

 In this technique we excise a oval portion
from mid and basal part of redundant anterior
leaflet . All the chordae attached to the
ventricular surface of the excised part are
separated and are reapplied to the remaining
leaflet after the defect in the remaining leaflet is
approximated by suturing the two parts.

 The technique is similar to the triangular
resection of PML.
 To be used when only a small part of the leaflet
is involved.
 Annulus distortion can occur if the involved
area is large.

 Using these techniques upto 90% of
degenerative mitral valves can be repaired.
 Hospital mortality is less than 1%.
 Overall 10 yr freedom from reoperation is
around 93%.
 Echocardiographic assessment results in 98%
10 yr and 97% 20 yr freedom from reoperation.
 Risk of repair failure is increased by anterior
leaflet prolapse, chordal shortening and failure
to use annuloplasty ring.

 Pathology of rheumatic heart disease produces
varying degrees of regurgitation, stenosis or mixed
lesions.
 Acute rheumatic valvulitis produces leaflet
prolapse and MR.
 Patients with RHD has components of restricted
leaflet motion producing stenosis or mixed
lesions.
 Restricted leaflet motion is caused by thickening of
subvalvular apparatus, thickening of leaflets and
chordae and commissural fusion. There may be
calcification of valve.

 Symptomatic MS is indication of surgery.
 A new onset atrial fibrillation
 A patient with pliable leaflets , no calcification,
normal chordae can be considered for repair.
 If the valve is severely distorted , leaflets are
heavily calcified and there is extreme subvalvar
fibrosis and shortening the valve should be
replaced.

 In patients with primary stenosis and limited
calcification and subvalvar thickening open
mitral commissurotomy is a good option.
 Commissurotomy should extend 2mm from
annulus. More extensive commissurotomy
causes MR.
 If MR occurs after commissurotomy
annuloplasty is done with ring.
 Patients with combined lesions are best served
by replacement.

 10 yr freedom from reoperation in patients
with repaired rheumatic mitral valve is around
72%.
 Open mitral commissurotomy provides 78-91%
10 yr freedom from reoperation.
 Durability of repair in RHD is limited with as
many as 50 % developing MR in 5 yrs.

 All the principles of repair are similar except
that all the infected material must be removed
and placement of any prosthetic material
should be avoided.
 There are 2 challenges:
1. Removing all infection and leaving sufficient
tissue for repair of valve.
2. Remodeling the annulus with autologus
material without implanting the prosthetic
ring.

 Pathologic findings include:
1. Chordal rupture(70%)
2. Vegetations (62%)
3. Leaflet perforation (53%)
4. Abscess (7%)

1. Heart failure nonresponsive to medical
therapy
2. Multiple embolic events
3. Uncontrolled sepsis
4. Extension of infection to surrounding
structures
5. Early operation is indicated for fungal and
staphylococcal infections.

 Includes:
1. Preservation of native , living valve apparatus
which is resistant to infection and concomitant
avoidance of prosthetic material.

 All the infected material is removed from
leaflet . Leaflets are completely detached from
the annulus and the annulus is debrided if
endocarditis involve the annulus and are
covered with pericardial lining before
reattaching the leaflets.
 Local treatment with iodine solution is
recommended.

 In case of ruptured chordae to posterior leaflet
quadrangular resection is performed.
 Anterior chordal rupture is repaired with
standard techniques.
 Anterior leaflet perforation are repaired with
autologus pericardial patch.
 Abscess cavities are debrided and excluded
with pericardial patch.
 Pericardial annuloplasty is done with both
active and chronic endocarditis.

 Around 80% of mitral valves with endocarditis
are amnable to repair.
 Hospital mortality is around 1-7%.
 Recurrent endocarditis is rare after mitral valve
repair.
 When compared with replacement ,repair of
infected mitral valve results in greater freedom
from recurrent infection and higher early and
late survival.

 1. clefts in posterior leaflet
 2. with annular calcifications
 3. systolic anterior motion
 4. Repair of ischemic MR.

 Clefts when present in posterior leaflet gets
accentuated after the repair
 Treatment is approximation of clefts using the
mattress suture by prolene 4-0.

 Seen mostly in elderly patients and in patients
with long standing disease.
 There are two sinarios:
a) If annulus is not affected by calcification and
calcification is only subannular: only partial
resection of calcification is required.
b) When there is extreme calcification of annular
and subannular tissue: separate atria from
ventricle and enblock resection of calcium is
done followed by reapproximation of atria and
ventricle

 SAM occurs due use of rigid annuloplasty
rings and when the height of the PML is
inadequately reduced for repair.
 In both of the situations the redundant PML
pushes the AML towards the septum in systole
and it results in approximation of AML to
septum which is enhanced in mid and late
systole due to venturi effect leading to LVOTO.

 SAM occurs in about 5-10 % cases of repair.
 In patients at risk SAM is potentiated by
hypovolemia, vasodiatation and use of
inotropes.
 More events of SAM are seen after
quadrangular resection and is minimised by
use of sliding plasty.

 Treatment of SAM:
1. Reresect the PML to reduce the height.
2. Upsize the annuloplasty ring.

 Mechanism of development of MR can be
derived from Carpentier’s functional
classification.
 According to it ischemic MR can result from
type I, II, IIIB dysfunctions.
 Carpentier’s IIIB dysfunction is most
common and significant form of ischemic MR.

« Surgeons are not basically concerned with lesions. We care more about
function. Therefore one may define the aim of a valve reconstuction as
restoring normal leaflet function rather than normal valve anatomy »
A. Carpentier, the French Correction 1984

 Development of type IIIB dysfunction results
due to :
1. Changes in ventricular wall: RWMA,
increased sphericity
2. Subvalvar changes includes fibrosis and
rupture of papillary muscles, teethering of
papillary muscles, apical and posterolateral
displcement of papillary muscle leading to
restriction of leaflet motion.
3. Annular dilatation and distortion due to
alteration in geometry of post infarction LV.

 Mechanism can be divided into 3 catagories.
1. Ruptured papillary muscles
2. Infarcted but unruptured papillary muscle
lads to fibrosis and chordal elongation.
3. Functional MR:
a. Left ventricular dysfunction and dilatation
b. Annular dilatation
c. Both LV dilatation and annular dilatation.

1. Severe ischemic MR
2. Mild to moderate ischemic MR: Controversial
A patient with ischemic MR of grade 2+ onwards
require mitral valve repair concomitant with
revascularization.

1. Median sternotomy is surgical approach of
choice.
2. Right lateral thoracotomy may be used in
patients with prior CABG and functioning
grafts. Here we perform right anterolateral
thoracotomy through 4th ICS.
3. Right thoracotomy is C/I inpatients with
previous right thoracic surgeries, COPD,
severe AR.

 Mitral valve repair is standard treatment for
ischemic mitral regurgitation.
 Here the anterior paracommissural scallop (P1
) constitutes the referance point.
 Mitral annulus is then examined to access the
dilatation.
 It is the P2 & P3 segments of posterior leaflet
which are most commonly involved as they are
attached to posterior papillary muscle which
has single blood supply.

 Remodeling annuloplasty using undersized
ring is the technique of choice in type IIIB
dysfunction.
 Most commonly braided 2-0 sutures are used
to implant the ring.
 The anterior commissure is the most difficult
area to expose for suture placement and is
generally approached last.
 Downsizing the physio ring by 1 or 2 sizes or
to use a true sized Mc Carthy-Carpentier IMR
Etlogix ring is used for annuloplasty.

 This IMR ring asymmetrically downsize the
annulus .this ring downsizes the D3 dimension
by 2 sizes and D2 dimension by 1 size. This
makes it possible to select true size ring.
Further more this ring contains titanium core
which allows complete fixation of septolateral
dimension during entire cardiac cycle.

 Papillary muscle rupture is managed by mitral
valve replacement with bioprosthesis.
 Papillary muscle infarction without rupture is
managed with repair techniques described
with degenerative mitral valve disease and
prolapse.
 If the portion of posterior leaflet is affected
quadrangular resection is indicated.
 If there is anterior leaflet prolapse , chordal
transfer and chordal replacement suffice.

 Hospital mortality after valve repair in
ischemic MR is around 3-6%.
 5 yr survival is around 58%.
 Patients with ruptured papillary muscle have
best long term survival , likely due to better
preservation of LV function.
 Patients with ischemic MR have more damaged
LV and correspondingly a reduced longevity.
 Because the long term survival is limited the
durability of mitral valve repair in patients
with ischemic MR is difficult to establish.

 Rings can be:
1. Rigid / flexible/ semiflexible
2. Complete/ incomplete/ asymmetric ring
Complete ring Incomplete ring
1. CE physio ring(titanium + velor
decron)
2. Medtronic complete flexible
ring(titanium core with silicon felt, 3
marks for referance.)
3. St jude semiflexible ring (AP
angulation)
4. Carbomedics complete flexible ring
1.CE ring made of titanium core.
2. Cogrove C shaped ring.
3. Homemade ring with stainless steel
wire.

 Choice of ring:
1. Degenerative diseases: rigid or flexible ring.
2. RHD/ endocarditis/ congenital mitral disease:
rigid ring.
3. Ischemic MR : rigid ring or asymmetric
ring(IMR ring by CE)
4. Functional MR: geoform ring
5. If underlying myocardium is severely diseased
the choice is rigid ring and if only valve tissue
is involved then incomplete ring is choice.

 Rigid rings: there occur no change in diameter
of ring in different parts of cardiac cycle. They
may interfere with LV filling and functioning,
LVOTO.
 Incomplete rings: they are used when only
annulus is dilated. No support to anterior part
of valve .
 Semiflexible rings: here the anterior portion is
rigid, so no change occurs in transverse
diameter. Posterior part is flexible so allows
change in transverse diameter of valve.

1. Retain the shape and size of annulus.
2. Keeps tension off the suture lines
3. Increases leaflet coaptation
4. Prevents recurrent dilatation of annulus.

 Hospital mortality for
isolated first time
elective MV repair is
2.5% (males) to 3.9%
(females)
 Operative risk is higher
in elderly pts,
associated CABG,
NYHA III-IV, low EF
and reoperation
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
Replacement Repair
Savage EB, et al Ann Thorac Surg 2003;75:820–5

 Older age is associated
to
 Higher mortality
 Higher morbidity
 Longer LOS
 2/3 of pts older than 70
years are denied surgery
(Euroheart Survey)
Mehta et al. Ann Thorac Surg 2002;74:1459-67

Braunberger, et al Circulation. 2001;104[suppl I]:I-8-I-11.

Years
100
Survival (%)
80
60
40
20
72%
Ejection Fraction
EF  60%
EF 50-60%
53%
EF < 50% 32%
P = 0.0001
0
0 2 4 6 8 10
Enriquez-Sarano M et al. Circulation 1994; 90: 830 - 37

• If mitral repair is performed before the onset of
severe symptoms (congestive heart failure,
arrhythmias), life expectancy is restored
David T et al, J Thorac Cardiovasc Surg 2003;125:1143-52

1072 patients with degenerative mitral regurgitation
operated upon at CCF between 1985 and 1997
Gillinov et alJ Thorac Cardiovasc Surg 1998;116:734-43

Flameng W, et al. Circulation. 2003;107:1609-1613

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