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Can mitral repair still be simplified ?
Pr Fabien DOGUET
Department of Cardiovascular and Thoracic SurgeryCHU Charles Nicolle, Rouen University Hospital
Rouen, France
Disclosure Statement of Financial Interest
I currently have, or have had over the last two years, an affiliation or financial interests or interests of any order with a company or I receive compensation or fees or research grants with a commercial company :
Speaker's name: Fabien, Doguet, Rouen
☑ I have the following potential conflicts of interest to report:
Consultant: Edwards, LivaNova, Abott
Why should we simplify mitral repair ?
The first step to standardize mitral repair
Techniques pioneered by Carpentier
• Quadrangular resection with annular plication
• Transfer of native chordae
• Papillary muscle shortening or plasty
Transposition chordae
But some techniques are not easy to use in minimal invasive surgery
Evolving techniques to treat leaflet prolaps
« Respect rather than resect »
Perier’s technique with the use of artificialneochordae
Emerging techniques
• Minimally-invasive techniques in MV repair: mini-thoracotomy video-assisted/robotic
• Perfect view on papillary muscle and leaflet prolaps
• Easier to use artificial chordae
• Difficulty to adjust length and securely fixing the chordae
What are the challenges using neochordae?
• How to determine the exact length of artificial chordae?
• How easily and securely fixing the chordae?
• How can we obtain a satisfactory long term result?
Remaining problems with AC: optimal length of chordae
• Too short: neochordae exert high tension on the valve
leaflet and papillary muscle (rupture, impair proper leaflet
motion)
• Too long: fail to repair the prolaps and increase the risk of
SAM
But it is not always easy to define the good length of artificialchordae…
… for the posterior leaflet
… for the anterior leaflet
3 simple techniques
to adjust the good lenght of AC
Techniques for the repair of posterior or both mitral leaflets
AATS Mitral Conclave 2013 Courtesy of Dr G Touati
« The Braids »
- Preoperative mesure with TEE
- 2*4/0 Gore Tex
- Length fixed with knots
Stages of Gortex custom-made standardized anterior and posteriormitral loops. (A) 15-mm self-made loop for the posterior valve.(B) 25-mm self-made loop for the anterior valve. (C) First stage of the 15-mm self-made loop. (D) First stage of the 25-mm self-made loop. (E) Several loops can be made with one Gortex suture as 15-mm loopsalone, 15/25-mm loops, or 25-mm loops according to the lesions of the mitral valve.
Preoperative planification
TOE (ex):
Large P2 prolaps
Small P2 prolaps (FED)
A2 Prolaps
2*15mm PTFE loops
1*15mm PTFE loop
2*25mm PTFE loops
During cardioplegia
Robotic cases
• Treat leaflet prolaps
• Anterior and/or posterior leaflet prolaps
• Only one technique to adjust the good length of artificial
chordae
• The aim is to adjust the length to the annulus plan
• Fixe the chordae easily and securely
• Real interest in MICS
Memo3D ReChordHow does it work ?
Memo3D ReChordhow does it work?
Anterior leaflet prolaps Posterior leaflet prolaps
The most complex case…but with the simplest treatment !
Simple repair approach for mitral regurgitation in Barlow disease
Simple repair approach for mitral regurgitation in Bar low disease
Sagit Ben Zekry, MD,a,c Dan Spiegelstein, MD,b,c Leonid Sternik, MD,b,c Innon Lev, MD,b,c
Alexander Kogan, MD,b,c Rafael Kuperstein, MD,a,c and Ehud Raanani, MDb,c
ABSTRACT
Objective: Mitral valve repair for myxomatous Barlow disease is a challenging
procedure requiring complex surgery with less than optimal results. The use of
ring-only repair has been previously reported but never analyzed or followed-
up. Weinvestigated thissimplevalverepair approach for patientswith Barlow dis-
ease and multisegment involvement causing mainly central jet.
Methods: Of 572 patients who underwent mitral valve repair for mitral regurgi-
tation at our medical center, 24 with Barlow disease (aged 47 14 years; 46%
male) underwent ring-only repair. Patients were characterized by severely
enlarged mitral valve annulus, multisegment prolapse involving both leaflets,
and demonstrated mainly a central wide regurgitant jet. Surgical technique
included only the implantation of a large mitral annuloplasty ring. Early and
lateoutcome resultswerecompared with thoseof the remaining patientswho un-
derwent conventional mitral valve repair for degenerative disease (controls).
Results: All ring-only patients presented with moderate-severe/severe mitral
regurgitation (vena contracta, 0.6 0.1 cm; regurgitation volume,
52 17 mL), with mainly a central jet and almost preserved ejection fraction
(59% 6%). Cardiopulmonary bypass and crossclamp times were significantly
shorter compared with controls (P < .0001). At follow-up (ring-only,
38 36 months and controls, 36 29 months), there were no late deaths in
the ring-only group compared with 19 (4%) in the controls. Late follow-up re-
vealed New York Heart Association functional class I or II in 95% of ring-only
patients, compared with 90% of controls. Freedom from recurrent moderate or
severe mitral regurgitation was 100% and 89% in the ring-only and control
groups, respectively.
Conclusions: Mitral annuloplasty for Barlow disease patientswith multisegment
involvement and mainly central regurgitant jet is both simple and reproducible
with excellent late outcomes. (J Thorac Cardiovasc Surg 2015;150:1071-7)
Transesophageal echocardiography. A-D, Before
valve repair. Eand F, After valve repair.
Central Message
A simple valve repair technique limited to
mitral annuloplasty for patients with Barlow
disease and multisegment involvement.
Perspective Statement
Mitral valve repair for myxomatous Barlow
disease is a challenging procedure. We present
a simple valve repair technique limited to
mitral annuloplasty. Thistechniquewasapplied
on 24 patients with Barlow disease and multi-
segment involvement causing mainly central
jet. Thetechniquewasfound to bereproducible
with excellent late outcomes.
See Editorial Commentary page 1078.
Supplemental material is available online.
Degenerativemitral regurgitation (MR) isthemost frequent
etiology for severe MR, accounting for most mitral valve
(MV) repair surgery. Based on surgical technique advance-
ment and improved surgical outcomes, the American
College of Cardiology/American Heart Association guide-
lines for valvular heart disease recommend MV repair
rather than replacement, specifying a class IIa indication
for high probabil ity of repair.1 Barlow disease, which ac-
counts for up to 30% of patients who undergo MV repair
surgery,2 is actually a spectrum of phenotypes with its
extreme form manifesting typically in young patients. It is
characterized by massiveannular dilation, excessthickened
leaflet tissue, with amultisegment prolapse, aswell aselon-
gated and weak chordae that may often cause flail leaflet.2
Repairing this complex form of Barlow pathology is
From the aNon-Invasive Cardiology Unit and bCardiac Surgery Department, Leviev
Heart Center, Sheba Medical Center, Tel Hashomer, Israel; and cSackler School
of Medicine, Tel Aviv University, Tel Aviv, Israel.
S.B.Z. and D.S. contributed equally to this work.
Received for publication May 30, 2015; revisionsreceivedJuly 27, 2015; accepted for
publication Aug 9, 2015; available ahead of print Sept 15, 2015.
Address for reprints: Ehud Raanani , MD, Cardiac Surgery Department, Leviev Heart
Institute, Sheba Medical Center, Tel Hashomer, Israel 52621 (E-mail : Ehud.
0022-5223/$36.00
Copyright Ó 2015 by The American Association for Thoracic Surgery
http://dx.doi.org/10.1016/j.jtcvs.2015.08.023
The Journal of Thoracic and Cardiovascular Surgery c Volume 150, Number 5 1071
ACQUIRED CARDIOVASCULAR DISEASE: MITRAL VALVE
AC
D
Figure 3
Schematic presentation of the mitral ring-only repair. Myxomatous disease is characterized by an enlarged annulus and excess leaflet tissue that has prolapsed (upper row). A triangle with an enlarged base can be draw between the mitral annulus and left ventricle apex (lower row). Placement of a ring and reducing annular size reduces the triangular base and thus mitral leaflets are pushed down toward the left ventricle to coapt at the left ventricle level. Note that leaflet dynamicity is preserved at the left ventricle level.
Symmetrical bileaflet prolaps
No chordal rupture
Significant annular dilatation
Wide central regurgitation jet
In conclusion
New simple techniques of mitral repair are required:
- To obtain 100% of mitral repair when repair is feasible
- With the development of minimal invasive mitral surgery
With the respect of principles of mitral repair:
- To restore a good surface of coaptation
- To correct abnormal valve motion
- To reshape and stabilize the mitral annulus