Ann Thorac Surg 1995;59:187-189
© 1995 The Society of Thoracic Surgeons
Mitral Valve Replacement With a Collar-Reinforced Prosthetic Valve for Disrupted Mitral Annulus
Yutaka Okita, MD,
Shigehito Miki, MD,
Yuichi Ueda, MD,
Takafumi Tahata, MD,
Tetsuro Sakai, MD,
Katsuhiko Matsuyama, MD
Department of Cardiovascular Surgery, Tenri Hospital, Nara, Japan
Accepted for publication August 23, 1994.
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Abstract
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The mitral valve was replaced with a collar-reinforced prosthetic valve in 6 patients with a disrupted mitral annulus, in 3 because of infective endocarditis, including 2 patients with prosthetic valve endocarditis, in 2 because of a severely calcified mitral annulus, and in 1 who had previously undergone mitral valve replacement twice. Four patients had undergone prior mitral operations; these consisted of mitral valve replacement in 3 patients and mitral valve repair in 1. In all patients, the prosthesis was secured by double-layered sutures, with the first row of buttressed sutures passing through the leaflet or sutured to the left ventricular muscle and through the sewing cuff of the prosthetic valve. The second row of running sutures was then placed through an extended annular equine pericardial cuff of the prosthetic valve and the supraannular left atrial wall. In 2 patients, all chordae tendineae were preserved to maintain annulopapillary muscle continuity. All patients survived and have remained well for a mean of 22.3 months. There has been no prosthetic valve dehiscence, except for minimal paraprosthetic leakage in 1 patient. These results demonstrate that mitral valve replacement in patients with a disrupted mitral annulus can be successfully accomplished with a collar-reinforced prosthetic valve.
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Introduction
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Disruption of the mitral annulus may result from infective endocarditis, bar calcification, or surgical trauma. Standard suture techniques for mitral valve replacement are often difficult to carry out, and paravalvular leakage, disruption of the left circumflex coronary artery, or rupture of the left ventricular wall may result [1, 2]. To prevent these complications from occurring, we used a technique involving the insertion of a composite mitral valve prosthesis with an annular equine pericardial cuff around the sewing ring.
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Patients and Methods
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Between December 1991 and August 1994, 6 patients at the Tenri Hospital underwent mitral valve replacement in which a collar-reinforced prosthetic valve was used. Patients ranged in age from 45 to 74 years. There were 5 men and 1 woman. Three patients had infective endocarditis, including 2 patients with prosthetic valve endocarditis; 2 had a severely calcified mitral annulus with severe mitral regurgitation; and 1 was suffering from paraprosthetic valve leakage after a second mitral valve replacement. Four patients had undergone prior mitral operations, including mitral valve replacement in 3 patients and mitral valve repair in 1. There were 2 patients in New York Heart Association functional class II preoperatively, 2 in class III, and 2 in class IV. The 3 patients with infective endocarditis underwent their operations on an emergent or urgent basis (Table 1
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Operations were performed in the setting of cardiopulmonary bypass, moderate hypothermia, and cardioplegic arrest. The composite prosthetic valve with a 1.5-cm-wide band of annular equine pericardium (Xenomedica; Edward AG, Switzerland) incorporated around the prosthetic sewing cuff (Fig 1) was secured using a double-layered suture technique. In patients with a calcified annulus, no attempts were made to remove the calcified bar in the posterior annulus. The first row of stitches, consisting of 2-0 polyester (Ethibond; Ethicon, Somerville, NJ) pledgeted mattress sutures, was placed through the leaflet tissue adjacent to the annular calcification from the left ventricle to the left atrium, and through the sewing cuff of the prosthetic valve. No sutures were placed through the calcified posterior annulus, but the anterior annulus was incorporated where appropriate. In 2 patients, all chordae tendineae were preserved to maintain annulopapillary muscle continuity. In patients with a mitral annular abscess, extensive debridement of the infected tissue was performed, and 2-0 polyester (Ethibond) pledgeted mattress sutures were placed through the remnant of the annulus or directly into the left ventricular muscle or in the left atrium. A second row of running stitches, using 4-0 polypropylene (Prolene; Ethicon) suture material, was placed through the pericardial cuff and extended to the supraannular left atrial wall (Fig 2). Intraoperative transesophageal echocardiography and a Doppler examination were routinely performed to confirm normal prosthetic valve function and the absence of paraprosthetic valve leakage.
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Fig 2. . Longitudinal view of the method of implanting a collar-reinforced composite prosthesis using double-layered sutures in a patient with mitral annular calcification. The prosthesis has an annular equine pericardial cuff around the sewing ring. (arrow = mitral annular calcification; asterisk = second row of 4-0 polypropylene running sutures; P = extended equine annular pericardial cuff; PML = posterior mitral leaflet; SJM = St. Jude Medical prosthesis; star = first row of pledgeted interrupted stitches [2-0 polyester].)
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Results
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No operative deaths, perioperative myocardial infarctions, or thromboembolic events occurred, and no reoperations were required. There has been no prosthetic valve detachment, except for minimal paraprosthetic leakage in patient 1. The postoperative left ventriculogram in this patient showed 1 to 2/4 regurgitation at the posterolateral mitral annulus. On follow-up 11 to 31 months after operation (mean, 22.3 months), all patients were in New York Heart Association functional class I or II. Echocardiograms obtained 5 to 29 months after operation did not document any cases of prosthetic valve detachment or deterioration of left ventricular function.
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Comment
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Although less common than aortic annular abscess, infective endocarditis may cause mitral annular abscess, resulting in the destruction of the fibrous ring and surrounding tissues. The surgical treatment of infective endocarditis involving disruption of the mitral annulus is associated with a high mortality because of the difficulty in eradicating the infection and in securing a prosthetic mitral valve. The left circumflex coronary artery is vulnerable, as it passes outside the posterior portion of the annulus in the atrioventricular groove. Prosthetic mitral valve endocarditis is more likely to cause damage to the annulus and lead to valve detachment, carrying a poor prognosis [3]. David and Feindel [4] described a technique for reconstructing the mitral annulus with autologous pericardium that was sutured directly to the endocardium of the left ventricle. In their series, 5 of 6 patients with active infective endocarditis and mitral annular abscess survived. Another option for mitral valve replacement in patients with mitral annular abscess was first reported by Gandjbackhch and associates [5], and involved the intraatrial insertion of a mitral prosthesis with a Dacron flange around the prosthetic valve. Although the results in their series were suboptimal (four early and two late deaths among 12 patients [6]), the concept of anchoring the prosthesis in two rows of sutures, thereby dispersing the hemodynamic stress, was widely accepted [7].
The mitral valve becomes calcified as a consequence of a degenerative process within the cardiac fibrous skeleton, mainly the posterior annulus of the mitral leaflet, which is followed by erosion through the calcification of the posterior mitral leaflet. The process is usually associated with myxomatous degeneration of the mitral valve. In patients who require operation for the treatment of mitral regurgitation, severe calcification of the annulus and the posterior mitral leaflet clearly precludes reconstruction, because most valve repair techniques require a pliable annulus and leaflets, unless complete removal of the calcified annulus is achieved. The alternative procedure in these cases is valve replacement, although the results of conventional techniques have usually been poor. Because the bar of calcification separates the left ventricle from the mitral annulus, partial debridement of the bar, brought about by passing sutures around or through the bar, increases the risk of circumflex coronary artery injury [8]. With the technique we describe here, the risks associated with debridement of the calcified annulus, as well as the risk of injury to the left circumflex coronary artery or of rupture of the posterior left ventricular wall, are avoided. Mills and associates [2] described similar techniques in which a Teflon cuff was used for mitral valve replacement in 5 patients with mitral annular calcification. They achieved excellent results, except for 1 case of paraprosthetic valve leakage. Coselli and Crawford [1] described a technique in which the mitral prosthesis is secured using valve leaflets, thereby preserving all chordae tendineae and the papillary muscle complex in the presence of a heavily calcified annulus. Ultrasonic debridement of the calcification of the annulus was reported by Eguaras and associates [8]; however, there is concern regarding the solidity of the mitral annulus after decalcification.
The mitral annulus may also be damaged iatrogenically during replacement with a mitral valve prosthesis. After removal of the prosthetic mitral valve, there may be inadequate fibrous tissue in the mitral annulus, and this may lead to prosthetic valve dehiscence or rupture of the posterior left ventricular wall.
Our experience with replacement of the mitral valve using a collar-reinforced prosthetic valve is limited and the duration of follow-up is relatively short. However, as no patient as yet has demonstrated any adverse effect or complication related to the technique, it should be one of the options for mitral valve replacement in patients with a disrupted fragile mitral annulus.
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Footnotes
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Address reprint requests to Dr Okita, Department of Cardiovascular Surgery, National Cardiovascular Center, Fujishirodai 5-7-1, Suita, Osaka, Japan 565.
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References
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- Coselli JS, Crawford ES. Calcified mitral valve annulus: prosthesis insertion. Ann Thorac Surg 1988;46:584–6.[Abstract]
- Mills NL, Macintosh CL, Mills LJ. Techniques for management of the calcified mitral annulus. J Cardiac Surg 1986;1:347–55.[Medline]
- Ergin MA, Raissi S, Follis F, Lansman SL, Griepp RB. Annular destruction in acute bacterial endocarditis. J Thorac Cardiovasc Surg 1989;97:755–63.[Abstract]
- David TE, Feindel CM. Reconstruction of the mitral annulus. Circulation 1987;76(Suppl 3):102–7.
- Gandjbackhch I, Laskar M, Pavie A, Mesnildrey P, Cabrol C. Implantation intra-atriale de la valve mitrale. Press Med 1983;12:1723–4.
- Jault F, Gandjbackhch I, Chastre JC, et al. Prosthetic valve endocarditis with ring abscesses. J Thorac Cardiovasc Surg 1994;105:1106–13.[Abstract]
- Kitamura N, Otaki M, Yamaguchi A, et al. Technique of mitral valve replacement with a collared prosthesis in patients with active prosthetic valve endocarditis. J Jpn Assoc Thorac Surg 1987;35:1643–9.
- Eguaras MG, Saceda JL, Luque 1, Concha M. Mitral and aortic valve decalcification by ultrasonic energy. J Thorac Cardiovasc Surg 1988;95:1038–40.[Abstract]
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Abstract
Introduction
