Mitral valve replacement with maintenance of mitral annulopapillary muscle continuity in patients with mitral stenosis

Abstract

Mitral valve replacement with maintenance of mitral annulopapillary muscle continuity in patients with mitral stenosis Postoperative left ventricular performance was evaluated in patients with mitral stenosis who underwent mitral valve replacement with maintenance of the continuity of the mitral anulus and papillary muscles. Mitral valve replacement with preservation of autologous chordae tendineae (n = 7) or their replacement with expanded polytetrafluoroethylene sutures (n = 14) was performed in 21 patients with mitral stenosis. Hemodynamic parameters were compared with those of 28 patients who underwent conventional mitral valve replacement and 27 patients who underwent open mitral valve commissurotomy. No deaths occurred in the early or late follow-up period. All hemodynamic parameters were improved after the operation, and no significant differences were detected among the three groups with regard to postoperative cardiac index or mitral valve area. No significant differences were observed in left ventricular end-diastolic volume index, end-systolic volume index, or contractility index, but the postoperative left ventricular ejection fraction in the chordal preservation and open commissurotomy groups was greater than that in the group having conventional mitral valve replacement. Postoperative regional shortening was greatest at the diaphragmatic portion in the chordal preservation group and at the long axis in the open commissurotomy group. In the mid-term postoperative period, although no differences were noted among the three groups in echocardiographic data or global ejection fraction measured by multigated equilibrium radionuclide angiography, the regional shortening at the anterolateral portion of the left ventricle in the chordal preservation and commissurotomy groups was greater than that in the group having conventional mitral valve replacement. Postoperative radionuclide angiography during exercise failed to demonstrate any difference between the ejection fraction in the chordal preservation group and that in the group having conventional mitral valve replacement. (J THORAC CARDIOVASC SURG 1994;108:42-51) Yutaka Okita, MD* (by invitation), Shigehito Miki, MD (by invitation), Yuichi Ueda, MD (by invitation), Takafumi Tahata, MD (by invitation), Tetsuro Sakai, MD (by invitation), and Katsuhiko Matsuyama, MD (by invitation), Nara, Japan Sponsored by Tadaomi Miyamoto, MD, Kitakyushu, Japan Eservation of the continuity between the mitral anulus and the papillary muscles results in improved postopera-From the

Chordal‐Sparing Mitral Valve Replacement Using Artificial Chordae Tendineae for Rheumatic Mitral Stenosis: Experience of the “Oblique” Method

“…David was first to report a reconstruction technique using synthetic chordae after excision of the mitral apparatus (14). Okita and coworkers reported good mid‐term results of chordal‐sparing MVR using ePTFE sutures in patients with MS and showed that postoperative LVEF after chordal‐sparing MVR was better than that in patients after conventional MVR (6). They placed 4 ePTFE sutures at the 2, 4, 8, and 10 o'clock positions on the mitral annulus.…”

“…Sakai and coworkers investigated the distance between the mitral annulus and the PM tip in 4 directions in 57 normal cadaveric hearts and found that the mean distance was about 23.5 mm, with no significant differences, in all directions (20). Okita and associates described that the length of their reconstructed artificial CT ranged from 2.0 to 2.3 cm, because in patients with MS the annulopapillary muscle distance in generally shorter than that in the normal heart (6). Since we have found that the distance is constant throughout the cardiac cycle in canine hearts (21), we believe that the length of the artificial CT can be determined during intraoperative cardiac arrest and may be suitable if the sutures are tied just less than taut.…”

“…Preservation of the chordae tendineae (CT) and papillary muscles (PMs) during mitral valve replacement (MVR) (1) has been known to enhance left ventricular (LV) function (2–4) in both the early and late stage after MVR (5). In patients with mitral stenosis, the diseased subvalvular apparatus often needs to be resected and replaced using artificial CT such as expanded polytetrafluoroethylene (ePTFE) sutures in order to achieve chordal‐sparing MVR (6). However, the optimal direction of alignment of the artificial CT has not been clearly defined.…”

Diretriz Brasileira de Valvopatias - SBC 2011/ I Diretriz Interamericana de Valvopatias - SIAC 2011

“…Consolidado o conceito, surgiram várias técnicas de preservação da cúspide posterior ou de ambas as cúspides, na troca valvar mitral, adaptadas às diferentes etiologias e contemplando tanto o uso de próteses mecânicas como biológicas. Na última década, por meio de pesquisas explorando os índices de função ventricular em repouso e em exercício, e os volumes ventriculares associados à sobrevida em longo prazo, foi comprovada a importância definitiva da preservação do complexo cordopapilar na melhora sustentada desses parâmetros 265,266 . Os efeitos benéficos da preservação estão associados à estrutura anatômica da valva mitral.…”

Posterior leaflet preservation during mitral valve replacement for rheumatic mitral stenosis

“…In comparison to the standard method, mitral valve replacement with posterior leaflet preservation showed better postoperative left ventricular performance and better late survival of patients 3,[10][11][12][13][14][15][16] . Regarding mitral stenosis, opinions are not uniform 2,[17][18][19] . Late postoperative morphological and functional changes of the left ventricle develop due to hemodynamic conditions and the presence of subvalvular structures that are liable to changes.…”