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Ann Thorac Surg 1995;59:52-55
© 1995 The Society of Thoracic Surgeons

Mitral Valve Replacement With Complete Retention of Native Leaflets

Division of Thoracic and Cardiac Surgery, University of Massachusetts Medical School, Worcester, Massachusetts

Accepted for publication June 21, 1994.

	Abstract

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Although both mitral leaflets contribute equally to the preservation of left ventricular function after mitral valve replacement, most surgeons routinely excise the anterior mitral leaflet. Possible disadvantages of leaflet retention are left ventricular outflow tract obstruction and interference with prosthetic valve motion. In 31 patients undergoing mitral valve replacement, all mitral valvular and subvalvular tissue was completely retained using a technique that involved reefing the native leaflets into the valve sutures. Fifteen Carpentier-Edwards porcine and 16 St. Jude Medical valves were implanted. Two patients died of causes unrelated to this technique. In the others, echocardiography demonstrated either no or an insignificant left ventricular outflow tract gradient, and, in most, no valvular tissue could be seen in the left ventricular outflow tract. No interference with prosthetic leaflet mobility occurred. The salutary results of mitral valve replacement with complete leaflet retention recommend its use.

	Introduction

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
The physiologic importance of the mitral subvalvular apparatus has been known since the early days of mitral valve replacement [1]. For many years, however, the standard technique for mitral valve replacement included excision of both leaflets and their attached chordae tendineae. Over the past several years, increased emphasis has again been placed on retention of the mitral subvalvular apparatus during valve replacement. This has been motivated by the proof of the dependence of left ventricular performance on the presence of the mitral valve and subvalvular apparatus, and of the improvement in left ventricular function associated with mitral valvuloplasty as opposed to that associated with standard mitral valve replacement [2–8]. However, most surgeons retain only the posterior leaflet and excise all or part of the anterior leaflet so as to prevent both interference with prosthetic valvular function and obstruction of the left ventricular outflow tract (LVOT) [1, 3, 4, 9].

During the past 4 years, we have retained all mitral leaflets and subvalvular apparatus in selected patients undergoing mitral valve replacement, proceeding on the hypotheses that the integrity of the anterior and posterior leaflets and subvalvular apparatus contributes equally to left ventricular function preservation and that LVOT obstruction and prosthetic dysfunction can be circumvented by reefing the leaflets. We describe the technique and our results.

	Material and Methods

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
The records of all patients who underwent mitral valve operations performed by one of the authors (T.J.V.) since January 1989 at the University of Massachusetts Medical Center were reviewed. Of this group, 31 patients were identified who had complete retention of all mitral tissue. The mean age of these patients was 68 years; 20 were more than 70 years of age. There were 18 women and 13 men. Both mitral leaflets were retained when at operation the pliable valve leaflets were found to be neither excessively thickened nor calcified. All patients had mitral regurgitation; one also had mitral stenosis. With the possible exception of the patient with mitral stenosis, mitral valvular degeneration caused the regurgitation. The available preoperative and postoperative echocardiograms were reviewed to assess the LVOT gradient, the presence of the anterior mitral leaflet in the LVOT, and mitral regurgitation.

The operation was performed through a median sternotomy, using moderate hypothermic cardiopulmonary bypass and cold blood cardioplegic arrest. After the left atrium was opened at the interatrial groove, the valve was sized without excising any mitral valvular or subvalvular tissue. Teflon felt pledget-reinforced horizontal mattress valve sutures (2-0 Ethibond; Ethicon, Somerville, NJ) were passed from the left atrium, through the mitral annulus, around the mitral leaflet, and up through the prosthetic annulus (Figs 1, 2). The prosthetic valve was then seated and the sutures tied, thus reefing the native leaflets and compressing them between the prosthetic and native annuli (Fig 3). Twelve tissue valves (Carpentier-Edwards; Baxter Healthcare, Santa Ana, CA) and 16 mechanical valves (St. Jude Medical, St. Paul, MN) were used. For the latter, prosthetic leaflet mobility was carefully assessed before the left atrium was closed. In 2 patients, a redundant chorda beneath the seated St. Jude Medical valve raised the possibility of future interference with leaflet motion; in both, the chorda was carefully excised without traumatizing the prosthesis. In 4 patients, severe mitral annular calcification was ultrasonically debrided using a previously reported technique [10].

View larger version (56K): [in this window] [in a new window]   Fig 1. . Valve sutures (with Teflon felt pledgets) placed as horizontal mattress sutures through the mitral annulus, around the valve leaflet, and out between the chordae tendineae.

View larger version (58K): [in this window] [in a new window]   Fig 2. . All sutures placed in the native valve and then threaded through the prosthetic annulus.

View larger version (47K): [in this window] [in a new window]   Fig 3. . Prosthetic valve seated and tied into place. Note the reefing of the native leaflets.

	Results

Top Footnotes Abstract Introduction Material and Methods Results Comment References

Preoperative cardiac catheterization or echocardiogram findings, or both, were compared with the postoperative echocardiogram findings. Of the 29 patients who survived the operation immediately, 28 had evaluable postoperative studies. Nine patients (4 with a St. Jude Medical valve and 5 with a Carpentier-Edwards valve) had trivial or 1+ mitral regurgitation revealed by Doppler echocardiography; none had clinical evidence of mitral regurgitation. Four patients had minimal LVOT gradients (10 to 13 mm Hg) but none of them had any observable anterior leaflet in the LVOT. Conversely, some anterior leaflet was seen in the LVOT in 4 patients, but all had a zero gradient across the LVOT. No patient had clinical evidence of LVOT obstruction. Most of the postoperative echocardiograms were obtained during the hospitalization for the operation; 16 studies were obtained from 1 month to 4 years postoperatively.

	Comment

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
In 1963, Lillehei suggested that the high mortality rate associated with mitral valve excision and replacement could be reduced by retention of the papillary muscles and chordae tendineae. He reported on the utility of this suggestion in an article describing his experience in 14 patients; all had survived and both the papillary muscles and their posterior chordal attachments had been preserved in all [1]. He excised the anterior leaflet in 13 patients but left it intact in 1. Although Cabrol [4] adopted the technique, Lillehei's teaching lay largely fallow for many years. In 1983, Hetzer and colleagues [11] revived the technique of posterior leaflet retention, and suggested that the continuity between the papillary muscles and mitral annulus was critical to the preservation of left ventricular function. This hypothesis has since been substantiated [2, 5, 6, 12, 13].

Retention of only the posterior leaflet with anterior leaflet resection has become the customary method of mitral valve replacement [1, 3, 4]. However, both the anterior and posterior mitral leaflets with their subjacent chordae and papillary muscles contribute equally to the preservation of ventricular function [14, 15]. There have been reports of LVOT obstruction following upon the retention of the anterior leaflet, both in patients who have undergone mitral valve replacements and in those who have undergone mitral valve repairs [9, 16, 17]. This, plus the fear that retained chordae might interfere with mechanical valve function, probably account for the reluctance of surgeons to retain the entire mitral valve. The technique described here eliminates both of these potential complications. By reefing the mitral leaflets within the valve sutures, the anterior leaflet cannot billow into the LVOT. At the same time, chordal tension on the ventricle is maintained and the chordae are pulled away from the valve effluent, thus eliminating interference with prosthetic leaflet motion.

There are other techniques for retaining some or most of the anterior leaflet and its subjacent chordae. David [18] described partial excision of the anterior leaflet with retention of most of the chordae. Miki and associates [19] described a technique involving making a T-shaped incision on the anterior leaflet and resuturing the two halves to the annulus near their respective commissures. In a subsequent paper, Okita and Miki and colleagues [20] demonstrated that left ventricular contractility was better preserved with this technique than it was with standard valve replacement. They also noted that regional wall motion was as good with this technique as it was with mitral valve repair, except at the inferolateral wall where it proved to be slightly better with repair. Feikes and co-workers [21] described their technique of disconnecting the anterior mitral leaflet from the annulus and incorporating it into the posterior valve sutures. In an experimental dog model, Moon and associates [15] confirmed the equally beneficial effect on left ventricular function achieved with either the posterior or anterior reattachment of the anterior leaflet, with both techniques accomplishing better preservation of left ventricular function than that achieved by the standard technique of leaflet excision.

Others have also made complete retention of the mitral leaflets a part of mitral valve replacement. Tyers [22], in an editorial, recommended a technique that appears identical to the one described here. He observed that LVOT obstruction could be prevented by ``rolling up the anterior leaflet like a Roman shade.'' Swain (personal communication) has also used the same technique with good results. And, in a randomized series of patients, Rozich and colleagues [13] observed that left ventricular function was better with retention of the chordae than with resection. In 3 of their patients, both anterior and posterior chordae were preserved, but they did not describe their technique.

Use of this technique may narrow or eliminate the advantages of mitral valve repair over replacement. There are two arguments in favor of using mitral valvuloplasty over replacement. The first is that the need for anticoagulants may be eliminated, and the second is that left ventricular function is better preserved with valvuloplasty than with conventional valve replacement. The second argument, based on the beneficial effects of retaining the mitral loop of the valve, chordae, papillary muscles, ventricular wall, and valve annulus, pertains equally to valvuloplasty and to valve replacement with complete retention of the mitral valve and subvalvular apparatus. Left ventricular function may also be altered by the nature of the annulus. Obviously all prosthetic valves have a rigid annulus, whereas some mitral annuloplasty rings are flexible. David and associates [23] demonstrated that left ventricular function was better preserved when a flexible rather than a rigid annuloplasty ring was used. However, Castro's group [24] cast doubt on that conclusion: they found no difference in left ventricular function when either a rigid or a flexible ring was used.

Balanced against the disadvantage posed by anticoagulant use in patients with mechanical valves are the assured longevity of the valve, the greater predictability of the result of replacement versus that of repair, and, for most surgeons, the easier and quicker performance of replacement than of repair. However, as more durable tissue valves (which do not require anticoagulation) become available, the first advantage of valvuloplasty disappears.

Initially we did not use this technique in patients with thickened or calcified valves, out of concern that the retained valve leaflets would either interfere with prosthetic function, or an excessively small prosthesis would be required. We have found, however, that some thickened valves lend themselves to this technique, and such replacements involve either leaving the leaflets intact or excising a central crescent (retaining the primary chordae) to reduce leaflet bulk. Similarly, in patients with mitral annular calcification extending onto the posterior leaflet, ultrasonic decalcification and debridement leaves pliable valvular and annular tissue that permits this technique to be applied. Nevertheless, because of severe fibrosis and subvalvular shortening, some valves may not be amenable to replacement with leaflet retention. However, neither are these valves amenable to valvuloplasty.

Preservation of the mitral valve and subvalvular apparatus maintains better ventricular function than that afforded by the conventional technique of valve replacement which involves mitral valve excision. This technique preserves the entire mitral valve, and eliminates the potential complication of LVOT obstruction or interference with prosthetic leaflet motion.

	Footnotes

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Address reprint requests to Dr Vander Salm, Division of Thoracic and Cardiac Surgery, University of Massachusetts Medical Center, 55 Lake Ave North, Worcester, MA 01655.

	References

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 

1. Lillehei CW, Levy MJ, Bonnabeau RC Jr. Mitral valve replacement with preservation of papillary muscles and chordae tendineae. J Thorac Cardiovasc Surg 1964;47:533–43.
2. Spence PA, Peniston CM, David TE, et al. Toward a better understanding of the etiology of left ventricular dysfunction after mitral valve replacement: an experimental study with possible clinical implications. Ann Thorac Surg 1986;41: 363–71.[Abstract]
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4. Cabrol CE. Comment on [3]. J Thorac Cardiovasc Surg 1984;88:724.
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6. Yun KL, Rayhill SC, Niczyporuk MA, et al. Mitral valve replacement in dilated canine hearts with chronic mitral regurgitation. Importance of the mitral subvalvular apparatus. Circulation 1991;84(Suppl 3):112–24.
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15. Moon MR, DeAnda A Jr, Daughters GT II, Ingels NB Jr, Miller DC. Experimental evaluation of different chordal preservation methods during mitral valve replacement. Ann Thorac Surg 1994;58:931–44.[Abstract]
16. Schiavone WA, Cosgrove DM, Lever HM, Stewart WJ, Salcedo EE. Long-term follow-up of patients with left ventricular outflow tract obstruction after Carpentier ring mitral valvuloplasty. Circulation 1988;78(Suppl 1):60–5.[Abstract/Free Full Text]
17. Mihaileanu S, Marino JP, Chauvaud S, et al. Left ventricular outflow obstruction after mitral valve repair (Carpentier's technique). Proposed mechanisms of disease. Circulation 1988;78(Suppl 1):78–84.
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21. Feikes HL, Daugharthy JB, Perry JE, Bell JH, Hieb RE, Johnson GH. Preservation of all chordae tendineae and papillary muscle during mitral valve replacement with a tilting disc valve. J Cardiac Surg 1990;5:81–5.[Medline]
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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Vander Salm, T. J. Articles by Mauser, J. F. Search for Related Content PubMed PubMed Citation Articles by Vander Salm, T. J. Articles by Mauser, J. F.