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Gillinov AM, Cosgrove DM III. Mitral Valve Repair.
In: Cohn LH, Edmunds LH Jr, eds. Cardiac Surgery in the Adult. New York: McGraw-Hill, 2003:933950.

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Chapter 37

Mitral Valve Repair

A. Marc Gillinov/ Delos M. Cosgrove, III

SURGICAL ANATOMY OF THE MITRAL VALVE
????Leaflets
????Annulus
????Chordae Tendineae
????Papillary Muscles
????Left Ventricle
DIAGNOSIS AND ASSESSMENT OF MITRAL VALVE DISEASE
????Clinical Findings
????Echocardiography
????Cardiac Catheterization
MITRAL VALVE OPERATION
????Anesthesia and Monitoring
????Mitral Valve Exposure
????Alternative Methods to Expose the Mitral Valve
????Valve Analysis
ETIOLOGY OF MITRAL VALVE DYSFUNCTION AND VALVE REPAIR
????Degenerative Mitral Valve Disease
????????SURGICAL INDICATIONS
????????REPAIR TECHNIQUES
????????RESULTS
????Rheumatic Mitral Valve Disease
????????SURGICAL INDICATIONS
????????REPAIR TECHNIQUES
????????RESULTS
????Ischemic Mitral Regurgitation
????????SURGICAL INDICATIONS
????????REPAIR TECHNIQUES
????????RESULTS
????Endocarditis
????????SURGICAL INDICATIONS
????????REPAIR TECHNIQUES
????????RESULTS
MINIMALLY INVASIVE MITRAL VALVE SURGERY
MITRAL VALVE REPAIR AND ATRIAL FIBRILLATION
REFERENCES

?? INTRODUCTION
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Mitral valve repair is the procedure of choice to treat mitral valve dysfunction of all etiologies.15 Advantages of mitral valve repair over mitral valve replacement include improved long-term survival, better preservation of left ventricular function, and greater freedom from endocarditis, thromboembolism, and anticoagulant-related hemorrhage.18 With the introduction of standardized surgical techniques by Carpentier, Duran, and others,711 mitral valve repair has become reproducible and widely disseminated. Repairable lesions in adult patients are caused by degenerative, rheumatic, ischemic, and endocarditic processes. Congenital mitral lesions in the adult are uncommon and will not be discussed.


?? SURGICAL ANATOMY OF THE MITRAL VALVE
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The mitral apparatus includes the leaflets, annulus, chordae tendineae, papillary muscles, and left ventricle.

Leaflets

The mitral valve has two leaflets, the anterior (aortic) and posterior (mural) leaflets. The leaflets are attached directly to the mitral annulus and to the papillary muscles by primary and secondary chordae. The anterior mitral leaflet is in direct continuity with the fibrous skeleton of the heart. This leaflet is contiguous with the left and noncoronary cusps of the aortic valve and the area beneath the intervening aortic commissure, termed the fibrous subaortic curtain. Although the anterior leaflet occupies only 35% to 45% of the annular circumference, its leaflet area is almost identical to that of the posterior leaflet.12

The posterior leaflet is rectangular. The free margin of the posterior leaflet has two variable indentations or clefts that divide the posterior leaflet into three scallops: the largest or middle scallop, the posteromedial scallop, and the anterolateral scallop. Fan-shaped chordae insert into and define the clefts between the individual posterior scallops. Motion of the posterior leaflet is more restricted than that of the anterior leaflet; however, both mitral leaflets contribute importantly to effective valve closure.

The surface of the mitral leaflet is divided into three zones corresponding to areas of chordal insertion and leaflet coaptation. The rough zone is the leading edge of the anterior and posterior mitral leaflets. This zone is the contact surface of the mitral leaflets during systole. The clear zone is peripheral to the rough zone and represents most of the body of the leaflet; this portion of the mitral valve billows into the atrium during ventricular contraction. The basal zone, between the clear zone and the annulus, receives the insertion of the basal chordae tendineae (tertiary chordae), which originate directly from the trabeculae of the left ventricle. The basal zone is found only on the posterior leaflet.

Annulus

The mitral annulus is the site of leaflet attachment to muscular fibers of the atrium and ventricle. The annulus is flexible and decreases in diameter during each systolic contraction by approximately 26%.13 The orifice of the mitral valve also changes shape, from elliptical during ventricular systole to circular during late diastole. This flexibility increases leaflet coaptation during systole and maximizes orifice area during diastole. Changes in size and shape of the annulus result from relaxation and contraction of the basoconstrictor muscles (bulbospiral and sinospiral bundles).14 In the horizontal plane the annulus is saddle-shaped. Anteriorly, the annulus is attached to the fibrous skeleton of the heart.15 This limits its flexibility and its capacity to dilate with mitral regurgitation (MR). The posterior annulus is more flexible and is not attached to rigid surrounding structures. This accounts for the clinical observation that dilation of the annulus occurs posteriorly with MR.16

Knowledge of the anatomy of the mitral annulus and surrounding structures is critical to avoiding inadvertent injury during mitral valve repair. The circumflex coronary artery courses laterally around the mitral annulus in the posterior atrioventricular groove (Fig. 37-1). The coronary sinus runs more medially in the same groove. The artery to the atrioventricular node, usually a branch of the right coronary artery, runs a course parallel and close to the annulus of the anterior leaflet near the posteromedial commissure. The aortic valve is situated between the anterior and posterior fibrous trigones. The bundle of His is located near the posterior trigone.



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FIGURE 37-1 Surgical anatomy of the mitral valve. Note proximity of the aortic valve and circumflex coronary artery.

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Chordae Tendineae

The chordae tendineae are chords of fibrous connective tissue that attach the mitral leaflets to either the papillary muscles or the left ventricular free wall. They often subdivide and interconnect before they attach to the leaflets. The chordae are divided into primary chordae, secondary chordae, and tertiary chordae. Primary chordae attach directly to the fibrous band running along the free edge of the leaflets. These chordae ensure that the contact surfaces (rough zone) of the leaflets coapt without leaflet prolapse or flail. Secondary chordae attach to the ventricular surface of the leaflets at the junction between the rough and clear zones. These chordae contribute to ventricular function. Secondary chordae enable the ventricle to contract in an efficient cone-shaped fashion; when secondary chordae are excised, the left ventricle assumes a globular shape.17,18 Tertiary chordae are unique to the posterior leaflet. They arise as strands directly from the left ventricular wall or from small trabeculae to insert into the ventricular surface of the leaflet near the annulus.

Papillary Muscles

The anterolateral and posteromedial papillary muscles each supply chordae tendineae to both leaflets. The two groups of papillary muscles subtend the anterolateral and posteromedial commissures and arise from the junction of the apical and middle thirds of the ventricular wall. The anterolateral papillary muscle receives a dual blood supply from the anterior descending coronary artery and either a diagonal branch or a marginal branch of the left circumflex artery.1921 The posteromedial papillary muscle receives its blood supply from either the left circumflex artery or a distal branch of the right coronary artery. Because of the single blood supply to the posteromedial papillary muscle, infarction of the posteromedial papillary muscle is much more common.

Left Ventricle

The posterior left ventricular wall and papillary muscles play an important role in leaflet coaptation and valve competence. Papillary muscles are aligned parallel to the ventricular wall and attach via chordae to the free edges of the valve leaflets. These muscles project from the trabeculae and may be single, bifid, or a row of muscles arising from the ventricular wall. During isovolumetric contraction the mitral leaflets are pulled downward and together by this interaction. Ventricular dilatation may affect the alignment and tension on the papillary muscles and valve competence.


?? DIAGNOSIS AND ASSESSMENT OF MITRAL VALVE DISEASE
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Clinical Findings

Patients with mitral valve dysfunction may be asymptomatic or present with manifestations of heart failure. Those with endocarditis generally have additional signs and symptoms caused by infection and embolization. Auscultation reveals murmurs typical of mitral regurgitation and/or mitral stenosis.

Echocardiography

Echocardiography is the standard diagnostic test for the evaluation of patients with suspected valvular heart disease. This technology provides a noninvasive method to evaluate the extent and cause of mitral valve dysfunction.22 In most cases, a preoperative transthoracic echocardiogram is sufficient to assess the mechanisms and degree of dysfunction and the feasibility of repair; if further morphologic information is necessary, a transesophageal echocardiogram is obtained.

Several qualitative, semiqualitative, and quantitative approaches are available to determine the severity of regurgitation and stenosis.23,24 Color flow Doppler mapping provides a rapid, semiqualitative evaluation of the size of the regurgitant jet.25 The maximal area of the regurgitant jet is expressed as a percentage of the area of the left atrium. The duration of the jet is also important. Pan-systolic jets involve a greater volume of regurgitant flow than jets of equal size but brief duration. Pulmonary venous flow is another index of the severity of mitral regurgitation.26 In severe MR, flow in the pulmonary veins reverses. There is no single method to quantitate the magnitude of MR; however, several techniques exist that, when taken together, provide an overall echocardiographic assessment of MR severity.

In addition to determining the degree of MR, echocardiography demonstrates the mechanism of dysfunction. The direction of the regurgitant jet is particularly helpful. In degenerative disease, the direction of the jet is usually opposite to the leaflet that prolapses. Thus, posterior leaflet prolapse causes an anteriorly directed jet, and anterior leaflet prolapse causes a posteriorly directed jet. Jet direction accurately predicts the mechanism of regurgitation in 80% of patients. Some patients have bileaflet prolapse; in these cases, there may be two or more jets within the atrium or a broad, central jet. Restricted leaflet motion characteristic of functional ischemic mitral regurgitation tends to cause a central jet.6 Eccentric jets occur occasionally when the jet originates from a commissure or from a leaflet perforation caused by endocarditis.

Echocardiography is also used to assess the severity and mechanisms of mitral valve dysfunction in patients with mitral stenosis. The severity of mitral stenosis is determined by measuring the mitral valve orifice area in the short-axis view during diastole.27 In mitral stenosis, valve leaflets are thickened or calcified and produce dense echo images. Leaflet excursion during diastole is reduced and opening of the valve is restricted. Doming of the anterior leaflet in diastole, i.e., the body of the leaflet moving more than the edge, is a pathognomonic feature of mitral stenosis. Using echocardiography, the feasibility of mitral valve repair is determined and information is obtained about chamber size, function, and other valvular abnormalities.

Cardiac Catheterization

Preoperative coronary angiography is recommended in all patients over 40 years of age and any patient with a history or clinical presentation suggesting the presence of coronary artery disease. While left ventriculography may demonstrate MR, much more information is gleaned from echocardiography. Mitral annular calcification visible on fluoroscopy indicates that mitral valve surgery will be complex.


?? MITRAL VALVE OPERATION
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Anesthesia and Monitoring

Patients undergoing mitral valve surgery are monitored with an arterial pressure line and transesophageal echocardiography; a pulmonary artery catheter is employed if there is ventricular dysfunction or an extensive operation is anticipated. Low-dose, short-acting narcotic anesthesia is supplemented by inhalation agents intraoperatively and short-acting intravenous sedation postoperatively to facilitate early extubation after surgery.

Mitral Valve Exposure

Excellent, consistent exposure of the mitral valve is essential for successful mitral valve repair. The traditional approach to the mitral valve includes median sternotomy, and that approach will be described here. Patients presenting for isolated, primary heart valve surgery are frequently candidates for minimally invasive approaches, and these will be discussed later.

After median sternotomy, the pericardium is opened slightly to the right of center and the right-sided pericardium tacked to the drapes under tension. Cardiopulmonary bypass is established with bicaval cannulation, and the heart is arrested with antegrade and retrograde blood cardioplegia. Thereafter, intermittent blood cardioplegia is delivered retrograde. The superior and inferior vena cavae are mobilized widely. A tourniquet is placed around the inferior vena cava with traction directed toward the patient's feet; this further elevates the right side of the heart.

To reduce the possibility of embolization of left atrial thrombus, the left atrium is not manipulated until after the aortic cross-clamp is applied. The field is flooded with CO2 at 6 L per minute; the CO2 displaces air, reducing the volume of intracardiac air.28 The left atrium is incised parallel to the interatrial groove. The incision is extended behind the superior vena cava and a considerable distance below the inferior vena cava. A specifically designed self-retaining retractor with three blades is used to facilitate exposure.29 The operating table is rotated away from the surgeon.

Exposure of the papillary muscles and the anterolateral commissure may require additional maneuvers.30 Exposure of the posteromedial papillary muscle is facilitated by sponges placed between the diaphragm and the diaphragmatic surface of the left ventricle. Gentle pressure with a sponge stick on the right ventricular outflow tract exposes the anterolateral commissure for annuloplasty suture placement.

Alternative Methods to Expose the Mitral Valve

Other approaches, often including alternative cardiac incisions, may be used to expose the mitral valve in particular circumstances. A right anterolateral thoracotomy is useful in patients with a previous sternotomy and patent coronary artery bypass grafts in the midline. Using this incision, cardiopulmonary bypass is established by peripheral cannulation, and the mitral valve is approached via the left atrium during a period of ventricular fibrillation. This approach may be quite challenging, as the mitral valve is at a distance from the skin incision.

In patients with a small left atrium and/or in a reoperative setting, an extended transseptal approach provides excellent exposure of the mitral valve. When this incision is used in a reoperation, left-sided cardiac adhesions need not be dissected. After opening the right atrium, the interatrial septum is incised and this incision is taken onto the dome of the left atrium. The incision on the dome of the left atrium should be kept at least 1 cm from the aorta to facilitate closure. Although the extended transseptal incision divides the artery to the sinus node and increases the incidence of postoperative junctional rhythm, the need for permanent pacemakers is not increased over a standard left atriotomy.31

Valve Analysis

Preoperative and intraoperative echo define the mechanism of mitral valve dysfunction before the valve is visualized. However, before beginning the repair, the surgeon performs a systematic examination of the valve. Although the mitral pathology is usually obvious, it is important to perform a complete assessment before committing to a repair strategy. The annulus is systematically evaluated for dilatation and/or deformity. Leaflets and leaflet motion are examined next. Nerve hooks are used to assess leaflet pliability and to assess leaflet prolapse or restriction. The motion of each leaflet is classified as normal (type I), prolapsed (type II), or restricted (type III).32 Lesions that produce MR with normal leaflet motion include annular dilatation and leaflet perforation. Lesions that produce regurgitation with prolapse include chordal rupture, chordal elongation, papillary muscle rupture, and papillary muscle elongation. Lesions that produce regurgitation with restricted leaflet motion include ventricular dilatation and dysfunction and rheumatic involvement of the subvalvular apparatus. After assessing the leaflets, the chordae are examined to evaluate length, thickening, fusion, or rupture. Finally, the papillary muscles are assessed, looking for elongation or rupture secondary to infarction.


?? ETIOLOGY OF MITRAL VALVE DYSFUNCTION AND VALVE REPAIR
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Degenerative Mitral Valve Disease

Also termed myxomatous mitral valve disease and floppy mitral valve disease, degenerative mitral valve disease is the most common indication for mitral valve surgery in North America and Europe.7,8,3336 Mitral valve prolapse occurs in 4% to 5% of the general population.37 Approximately 5% of patients with prolapse ultimately develop MR that requires surgery.3741

Ninety percent of degenerative mitral valves are amenable to repair.36 However, pathology in degenerative valve disease varies considerably and influences the complexity of repair. The classic features of degenerative mitral valve disease include leaflet prolapse and annular dilatation.79 Chordae may be elongated and thinned, ruptured, or thickened. The posterior leaflet and its chordae are affected more commonly than is the anterior leaflet. Posterior chordal rupture is the most common finding, occurring in 50% of patients.7 Such patients most commonly have prolapse or flail of the middle scallop of the posterior leaflet.

SURGICAL INDICATIONS

Symptomatic patients with degenerative mitral valve disease and 3+ or 4+ mitral regurgitation should be referred for surgery. Asymptomatic patients with 3+ or 4+ mitral regurgitation and a decrease in left ventricular function as demonstrated by resting or stress echocardiography, left ventricular dilatation, or new onset atrial fibrillation should also be referred for surgery.4247

REPAIR TECHNIQUES

Quadrangular resection Posterior leaflet prolapse is treated by quadrangular resection (Fig. 37-2). The portion of the posterior leaflet with elongated or ruptured chordae is identified. Stay sutures are placed around normal chordae on either side of the diseased chordae to demarcate the area of resection. The segment of posterior leaflet with diseased chordae is then resected using a knife and scissors. The resulting gap in the annulus is closed with 1 or 2 pledgeted sutures; this annular plication is a critical step in the repair, and these sutures must be placed in firm annular tissue. After tying the annular plication sutures, the leaflet edges should not be under tension. The leaflet edges are reapproximated using running 5-0 braided suture. An annuloplasty completes the repair. Occasionally, two posterior leaflet quadrangular resections are performed in the same patient.



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FIGURE 37-2 Posterior leaflet quadrangular resection. (Top) After leaflet resection, the annulus is plicated with one or two pledgeted sutures. (Bottom) The leaflet edges are approximated, and an annuloplasty completes the repair.

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Quadrangular resection may also be performed to treat ruptured chordae at a commissure. However, commissural prolapse is most easily managed by simple closure of the commissure.

Sliding leaflet repair The sliding leaflet repair, a variant of posterior leaflet quadrangular resection, was devised by Carpentier to prevent left ventricular outflow tract obstruction caused by systolic anterior motion (SAM) of the anterior leaflet of the mitral valve.48 SAM occurs only in patients having quadrangular resection for degenerative disease, and, before development of the sliding leaflet repair, SAM complicated repair in 5% to 10% of cases.4951 SAM develops in patients with excess leaflet tissue; in such cases, after the repair, the line of leaflet coaptation is displaced anteriorly by redundant posterior leaflet tissue, and the long anterior leaflet obstructs the left ventricular outflow tract.52,53 SAM may occur with a rigid annuloplasty ring, a flexible annuloplasty ring, or no annuloplasty ring.50,5456 In patients at risk, SAM is potentiated by hypovolemia, vasodilatation, and administration of inotropes. In mild cases of SAM occurring after repair, volume loading, inotrope cessation, and administration of afterload-increasing agents suffice to reduce or eliminate the hemodynamic consequences of SAM.54 In such mild cases, SAM will usually regress with time.54

The best strategy in patients at risk for SAM is prevention by sliding leaflet repair.57 The sliding leaflet repair is used as an adjunct to quadrangular resection in patients with excess leaflet tissue and a posterior leaflet with a height of more than 1.5 cm (Fig. 37-3). The primary purpose of the sliding leaflet repair is to reduce the height of the posterior leaflet, thereby moving the point of systolic leaflet coaptation posteriorly. After quadrangular resection, the posterior leaflet is detached from the annulus for a distance of 1.5 to 2 cm on either side of the resection. Annuloplasty sutures are easily placed once the leaflet is detached. Then the leaflet is reapproximated to the annulus using running 4-0 polypropylene suture. Deep bites are taken in the posterior leaflet, thereby reducing its height. The leaflet edges at the site of resection are reapproximated with running 5-0 multifilament suture, and an annuloplasty completes the repair. This procedure has virtually eliminated the risk of SAM in patients with degenerative disease.57,58



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FIGURE 37-3 Sliding leaflet repair to prevent SAM. (Top) After leaflet resection, the posterior leaflet is detached from the annulus for a distance of 1 to 2 cm toward each commissure. (Middle) Annuloplasty sutures are placed, and the leaflet is reattached to the annulus. (Bottom) The leaflet edges are reapproximated, and annuloplasty completes the repair.

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Anterior leaflet prolapse A variety of techniques have been used to treat anterior leaflet prolapse. The most popular include chordal transfer, chordal replacement, and chordal shortening. Anterior leaflet resection is rarely indicated.

Chordal transfer is our favored technique for treating anterior leaflet prolapse. Normal primary chordae from the posterior leaflet or secondary chordae from the anterior leaflet are transposed to the unsupported region of the anterior leaflet. The advantage to this procedure is that precise measurement of the transfered chordae is unnecessary; provided that they are not diseased, the transferred chordae are always the right length.

For posterior chordal transfer, a segment of the posterior leaflet and its normal chordae are detached from the posterior annulus (Fig. 37-4).



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FIGURE 37-4 Chordal transfer from posterior to anterior leaflet. In order to support a portion of anterior leaflet with ruptured chordae, a segment of the posterior leaflet with its attached chordae is transferred to the anterior leaflet.

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The detached segment is then sewn to the unsupported portion of the anterior leaflet using interrupted 4-0 braided suture. The defect in the posterior leaflet is repaired as for standard quadrangular resection. When anterior leaflet secondary chordae are transposed to the free edge of the anterior leaflet, they are simply detached and sutured into place (Fig. 37-5).



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FIGURE 37-5 Chordal transfer from anterior leaflet. A normal secondary chord is transferred from the body to the free edge of the anterior leaflet to correct prolapse caused by anterior chordal rupture.

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Chordal replacement is another option for correction of anterior leaflet prolapse. David and others have extensive favorable experience with this technique.59,60 PTFE suture (4-0 or 5-0) is the preferred material for chordal replacement. The neochordae are affixed to the fibrous portion of the papillary muscle and then passed through the leaflet one or more times and tied. The primary challenges with this technique are judging the length of the chordae and tying the PTFE. Several authors have reported ingenious solutions to these problems.59,60

Chordal shortening was one of the original techniques described by Carpentier for management of anterior leaflet prolapse.36 The pathologic, elongated chord is shortened by tucking it into a papillary muscle trench or affixing a portion of the chord to the side of the papillary muscle. Alternatively, the chord may be shortened at its insertion into the mitral leaflet.61 Durablility of these techniques is jeopardized by late rupture of previously shortened chordae.7,62,63 At The Cleveland Clinic Foundation, we prefer chordal transfer for correction of anterior leaflet prolapse.

Annuloplasty Annular enlargement is present in patients with degenerative disease. Usually, annular dilatation occurs only along the posterior annulus because the anterior annulus is attached to the fibrous skeleton of the heart. Annuloplasty is a component of the repair in all patients with degenerative disease. Annuloplasty is performed to correct annular dilatation, increase leaflet coaptation, reinforce suture lines, and prevent further annular dilatation. A variety of annuloplasty rings are available; all provide excellent results in patients with degenerative disease.7,8,64 Rings may be flexible or rigid, complete or incomplete.6467

When placing annular sutures, relatively deep bites through the annulus are required. Posteriorly, the needle should be directed toward the ventricular cavity in order to avoid injury to the circumflex coronary artery (see Fig. 37-1). It is important to place sutures in the fibrous trigones, which are located near the commissures and may be visible as indentations in the endocardium. If a circumferential annuloplasty is used, care must be taken not to injure the aortic valve anteriorly.

Calcified annulus In patients with degenerative disease, the posterior mitral annulus may be calcified. Annular decalcification is necessary to facilitate annuloplasty placement. When calcium is not extensive, simple debridement suffices. In the setting of dense posterior annular calcification, the calcium may be removed piecemeal or en bloc.6870 In order to facilitate debridement, the posterior leaflet is detached from the annulus as in a sliding leaflet repair. After debridement, if there is a concern about posterior ventricular rupture, a pericardial patch is used to cover the weakened area. The patch is affixed to ventricular and left atrial muscle. The leaflets are then attached to the patch at the annular level.

Alfieri edge-to-edge repair Alfieri et al described the edge-to-edge repair.71,72 When employed to correct anterior leaflet prolapse, a suture affixes the free edge of a segment of normal posterior leaflet to the free edge of a prolapsing portion of the anterior leaflet. The normal posterior leaflet with its chordae serves to anchor the anterior leaflet, restricting its motion. This technique is particularly useful when anterior leaflet prolapse is the primary pathology and posterior annular calcification renders chordal transfer problematic.

RESULTS

Using these techniques, 90% of degenerative mitral valves can be repaired. For isolated mitral valve repair, hospital mortality is less than 1%, and repair results in survival curves similar to those of the general population.7,8 Degenerative disease is associated with the most durable mitral valve repairs. Overall, 10-year freedom from reoperation is 93%; posterior leaflet repair with quadrangular resection and annuloplasty and echocardiographic assessment results in 98% 10-year and 97% 20-year freedoms from reoperation.7,8,33,36 Risk of repair failure is increased by anterior leaflet prolapse, chordal shortening, and failure to use an annuloplasty or intraoperative echocardiography.7,8,73 After repair, patients should not leave the operating room with more than 1+ MR.74,75

Rheumatic Mitral Valve Disease

The prevalence of rheumatic mitral valve disease has been decreasing in surgical practice in North America and Europe. This is attributable to the reduced incidence of the disease and the advent of percutaneous balloon mitral valvuloplasty to treat mitral stenosis.76,77

Pathologic features of rheumatic mitral valve disease produce varying degrees of regurgitation, stenosis, or mixed lesions.78 Acute rheumatic valvitis produces leaflet prolapse and MR; these features are uncommon in North America.79 Most patients presenting for evaluation have some component of restricted leaflet motion, producing mitral stenosis or a mixed lesion.80 Restricted leaflet motion is caused by thickening of the subvalvular apparatus, thickening of the leaflets, and commissural fusion; there may also be calcification of any component of the valve.

SURGICAL INDICATIONS

Symptomatic mitral stenosis or regurgitation is an indication for intervention. New onset atrial fibrillation is also an indication for intervention. Patients with mitral stenosis and low echocardiographic scores should have percutaneous balloon valvotomy.81,82 Patients with higher echo scores (>8) should be offered surgery. In such patients, if the anterior leaflet and chordae are pliable, repair is considered.80,83 In contrast, if the valve is severely distorted, the leaflets heavily calcified, or the papillary muscles fused to the leaflet edges, the valve should be replaced.

Pure rheumatic mitral regurgitation is uncommon. Durability of repair for this entity is limited.84 In such patients, repair may be offered as a palliative option, particularly if there are compelling reasons to provide a period of time during which the patient will not require anticoagulation (e.g., childbearing).

Patients with mixed rheumatic stenosis and regurgitation present a particular technical challenge and are least amenable to repair.85 If valve distortion is not severe and the anterior leaflet and chordae are pliable, repair may be considered.

REPAIR TECHNIQUES

In North America, most patients who present for surgical treatment of rheumatic mitral valve disease have severely deformed valves that are best suited to replacement.80 However, in patients with primary mitral stenosis and limited calcification and subvalvular thickening, open mitral commissurotomy is a good option. The commissurotomy should extend to 2 mm from the annulus; more extensive commissurotomy may cause MR. If there is MR after commissurotomy, an annuloplasty is added. Debridement of calcium and fibrous peel from the leaflets is an adjunctive measure employed in some patients.

Rheumatic MR from leaflet prolapse is repaired using techniques such as chordal transfer and creation of artificial chordae.79 An annuloplasty is incorporated in these repairs.

Patients with combined mitral stenosis and regurgitation are usually best served by replacement. When repair is attempted, a combination of techniques described above is necessary.

RESULTS

Mitral valve repair may confer a survival advantage when compared to mitral valve replacement in patients with rheumatic disease.80,86 Overall, 10-year freedom from reoperation in patients with repaired rheumatic valves is 72%.80 However, the feasibility and durability of repair are influenced strongly by the valve pathology. In appropriately selected patients with pure mitral stenosis, open mitral commissurotomy provides excellent results, with 78% to 91% 10-year freedom from reoperation.87,88 However, durability is particularly limited in young patients with acute rheumatic carditis and prolapse; nearly half of these patients develop severe recurrent MR within 5 years.84 In patients with mixed lesions, valve morphology usually limits the ability to achieve a satisfactory repair; when repair is attempted in such patients, durability is limited, with half of patients requiring reoperation within 14 years.83,85

Ischemic Mitral Regurgitation

Ischemic mitral regurgitation is MR that is caused by coronary artery disease.6 As such, ischemic MR must be distinguished from organic mitral valve disease with coexisting coronary artery disease. In patients with ischemic MR, the valve leaflets and chordae appear normal.89,90 The MR is a direct consequence of left ventricular dysfunction. Ischemic MR may be transient, a result of reversible ischemia that causes ventricular dysfunction. In this setting, relief of ischemia generally causes MR to decrease or disappear, and a mitral valve procedure is unnecessary. More commonly, ischemic MR is a consequence of previous myocardial infarction.

Ischemic MR caused by previous myocardial infarction is subdivided into three mechanisms: (1) ruptured papillary muscle, (2) infarcted papillary muscle without rupture, and (3) functional regurgitation (Table 37-1). Ruptured papillary muscle is most frequently caused by infarction in the circumflex or right coronary artery distribution. Patients with elongated and infarcted but unruptured papillary muscles have leaflet prolapse. Patients with isolated functional MR have normal papillary muscles, chordae, and leaflets; however, the leaflets fail to coapt. Failure of coaptation is caused by annular dilatation, leaflet tethering, or both (Fig. 37-6). Myocardial infarction produces ventricular dilatation and dysfunction, and the resulting geometric changes prevent leaflet coaptation. These changes in annular and ventricular geometry are usually caused by myocardial infarction in the circumflex or right coronary artery distributions.6,91,92 Using echocardiography, the majority of patients with ischemic MR can be placed into one of these groups.


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TABLE 37-1 Mechanisms of ischemic mitral regurgitation

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FIGURE 37-6 Functional ischemic mitral regurgitation occurs when ventricular dilatation and dysfunction cause leaflet tethering, preventing normal leaflet coaptation.

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SURGICAL INDICATIONS

Patients with acute ischemic MR and active myocardial ischemia are most commonly treated by a combination of medical therapy and percutaneous coronary intervention. However, in instances of important left main coronary artery disease or severe three-vessel coronary artery disease, they may require urgent surgical revascularization. When surgery is required in these patients, a mitral valve procedure is deferred until examination of the postbypass echocardiogram; if MR of 2+ or higher persists, a mitral procedure is then performed.

Papillary muscle rupture causes cardiogenic shock. After diagnosis by echocardiography and coronary angiography, an intra-aortic balloon pump is placed and emergency surgery is performed. When patients with papillary muscle infarction and elongation without rupture develop 3+ or 4+ MR and congestive symptoms, surgery is indicated.

Surgical indications for patients with functional ischemic MR are controversial. The degree of MR should be established by preoperative echocardiogram, as intraoperative echocardiogram tends to result in downgrading of MR due to changes in loading conditions.6,92 These patients present for combined coronary artery bypass grafting and mitral valve surgery or isolated mitral valve surgery. In patients undergoing coronary artery bypass grafting, 3+ or 4+ MR should be addressed. In patients with 2+ MR, we favor mitral valve repair at the time of coronary artery bypass grafting. Currently, however, data are lacking to support an advantage to this approach.

Selected patients with ischemic cardiomyopathy and functional MR should be offered mitral valve repair.9396 These patients should be offered surgery only if they have 3+ or 4+ MR. Such patients should have a preoperative viability study to assess the need for coronary artery bypass grafting.

REPAIR TECHNIQUES

Papillary muscle rupture should usually be managed by mitral valve replacement with a bioprosthesis.6,97 Although occasional patients may be treated by reimplantation of a ruptured papillary muscle head into adjacent viable myocardium, such a strategy subjects a critically ill patient to the possibility of catastrophic early or late repair failure caused by recurrent rupture.

Papillary muscle infarction with elongation is managed using the techniques described for patients with degenerative mitral valve disease and prolapse. If a portion of the posterior leaflet is affected, quadrangular resection is indicated. If there is anterior leaflet prolapse, chordal transfer or chordal replacement suffices. Occasionally, papillary muscle shortening is employed.98

Functional ischemic MR is generally managed with annuloplasty alone. The annuloplasty should be undersized in order to increase maximally leaflet coaptation.6,93 The precise type of annuloplasty (flexible vs. rigid, complete vs. incomplete) is controversial.6,93 We favor an undersized, flexible, posterior annuloplasty. If, on static testing in the arrested heart, it appears likely that a leak will remain after annuloplasty, an Alfieri stitch may be added. This is generally placed in the middle of the valve, or, occasionally, toward the posteromedial commissure.96 If leaflet tethering is extensive and annuloplasty fails, mitral valve replacement with a bioprosthesis and preservation of the subvalvular apparatus is indicated.99

RESULTS

Surgical treatment of ischemic MR is associated with poor long-term survival. Hospital mortality after valve repair in patients with ischemic MR is 3% to 6%.6 However, 5-year survival is only 58%.6 The mechanism of MR influences survival.6,89,91 Patients with ruptured papillary muscle have the best long-term survival, likely related to better preservation of left ventricular function.6 Patients with functional ischemic MR have more LV damage and correspondingly reduced longevity. The majority of patients with ischemic MR benefit from mitral valve repair versus replacement. Replacement should be reserved for patients in whom repair fails or is not feasible. In addition, the most critically ill patients should receive bioprostheses; in such patients, there is no survival benefit to repair.

Because long-term survival is limited, the durability of mitral valve repair in patients with ischemic MR is difficult to establish. Bolling and others report excellent freedom from recurrent MR in patients with ischemic cardiomyopathy.93,96 This success is attributed to a combination of small annuloplasty ring size and favorable ventricular remodeling. There is no large study documenting long-term echocardiographic follow-up in patients having mitral valve repair for ischemic MR.

Endocarditis

Native valve endocarditis is generally caused by streptococcal or staphylococcal species.100103 Pathologic findings include chordal rupture (70%), vegetation (62%), leaflet perforation (53%), and abscess (7%).100

SURGICAL INDICATIONS

Surgical indications are well established.104107 They include heart failure unresponsive to medical therapy, multiple embolic events, uncontrolled sepsis, and extension of infection into surrounding structures. In addition, early operation is indicated for fungal and staphylococcal infections. Potential advantages of mitral valve repair in the setting of infection include preservation of the native, living valve apparatus, which is resistant to infection, and corresponding avoidance of prosthetic material.100103

REPAIR TECHNIQUES

Radical debridement is the cornerstone of operative treatment of endocarditis.103 All infected material must be removed. If there are ruptured chordae to the posterior leaflet, quadrangular resection is performed. Anterior chordal rupture is repaired with standard techniques. Anterior leaflet perforations are repaired with autologous pericardial patches; it is not necessary to fix or tan the pericardium. Abscess cavities are debrided and excluded with a pericardial patch.108 We favor posterior pericardial annuloplasty in both active and chronic endocarditis.100

RESULTS

Eighty percent of infected mitral valves are amenable to repair.100 Hospital mortality is 0% to 7%.100103 Recurrent endocarditis is rare after mitral valve repair.100103 When compared to replacement, repair of the infected mitral valve results in greater freedom from recurrent infection and higher early and late survival.100


?? MINIMALLY INVASIVE MITRAL VALVE SURGERY
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A variety of less invasive approaches have been developed to perform isolated mitral valve surgery or combined mitral and aortic valve surgery. Chest wall incisions include right parasternal,109 right thoracotomy,110112 partial lower sternotomy,113 and partial upper sterntomy.31,114 Adjunctive techniques employed for mitral valve surgery include Port-Access instrumentation,115,116 video assistance,110,111 and robotic assistance.117119 Excellent results have been reported with each of these approaches.

We favor partial upper sternotomy access for isolated valve surgery. This approach affords the surgeon a familiar orientation. Central cannulation is possible in all cases, and exposure of the mitral valve is excellent. Through a 6-cm skin incision, a partial upper sternotomy extends from the sternal notch to the left 4th intercostal space (Fig. 37-7). Cardiopulmonary bypass is accomplished via bicaval and aortic cannulation. Vacuum-assisted venous drainage allows the use of smaller, less obstructive cannulae, reduces the priming volume of the cardiopulmonary bypass circuit, prevents air locks, and keeps the field dry. After opening the right atrium, a cannula is placed in the coronary sinus for delivery of retrograde cardioplegia. The mitral valve is approached through a transseptal incision that is extended onto the dome of the left atrium. This exposure of the mitral valve facilitates both simple and complex repair procedures.




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FIGURE 37-7 Minimally invasive mitral valve repair. Partial upper sternotomy provides access. The mitral valve is approached via an extended transseptal incision.

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This approach has been used in more than 1400 mitral valve procedures at the Cleveland Clinic Foundation; 90% of these patients had mitral valve repair. Conversion to full sternotomy was necessary in 1% of cases. Hospital mortality was 0.3%. This is now our approach of choice in patients with isolated heart valve disease.


?? MITRAL VALVE REPAIR AND ATRIAL FIBRILLATION
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Thirty to fifty percent of patients presenting for mitral valve surgery have atrial fibrillation.120 In such patients, an important goal of the procedure is ablation of atrial fibrillation in addition to mitral valve repair. When atrial fibrillation has been present for less than 1 year, mitral valve repair alone is likely to cure the atrial fibrillation.120123 In contrast, when atrial fibrillation has been present for more than 1 year, 80% of patients will remain in atrial fibrillation, requiring coumadin after mitral valve repair.121 Therefore, surgical ablation of atrial fibrillation is indicated in patients having mitral valve surgery who have a history of more than 1 year of paroxysmal, persistent, or permanent atrial fibrillation.

A variety of surgical procedures are available for ablation of atrial fibrillation, ranging from the Cox-Maze III procedure to pulmonary vein isolation using alternative energy sources.120,124130 Alternative energy sources currently available to create lines of conduction block include microwave, radiofrequency, cryothermy, and laser. Use of alternative energy sources decreases the operative time and reduces the risk of bleeding. These are generally used to create left atrial lesion sets that include pulmonary vein isolation and connecting lesions to the left atrial appendage and to the mitral annulus.120,130 This is based upon current concepts regarding the pulmonary veins and left atrium in the genesis of atrial fibrillation.131,132 Right atrial lesions are frequently omitted, as atrial fibrillation rarely arises from the right atrium.

The Cox-Maze III procedure cures atrial fibrillation in 80% to 100% of patients having concomitant mitral valve surgery.124,125 Increased left atrial size and rheumatic disease may limit success. Early data suggest that use of alternative energy sources to create left atrial lesion sets ablates atrial fibrillation in 70% to 80% of patients.120 Given these data, patients with preoperative atrial fibrillation of more than 1 year's duration should have surgical ablation of atrial fibrillation in addition to mitral valve repair. In such patients, this strategy is the only means to avoid lifelong anticoagulation and its attendant risks.


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