Tutorial
Bileaflet pericardial patch repair for rheumatic mitral valve disease
Surgical repair in rheumatic mitral valve disease is technically challenging as the disease affects both valvular and subvalvular structures. Due to the resultant shortage of pliable valve tissue, pericardial patch techniques are progressively used to restore normal valve function. This makes mitral valve repair possible even in the most severe forms of rheumatic mitral valve disease.
In this tutorial, we report a case of mitral valve repair with a bileaflet (decellularized) pericardial patch in a patient with severe rheumatic mitral valve disease.
Surgical mitral valve repair is the treatment of choice in organic mitral valve disease. However, in the setting of rheumatic mitral valve disease, valve repair remains controversial. Rheumatic mitral valve disease is characterized by leaflet fibrosis and calcification, often resulting in a shortage of pliable leaflet tissue needed to secure a durable valve repair. As disease progression often causes restenosis and insufficiency, primary mitral valve replacement remains commonly performed. Alternatively, pericardial patch techniques can be used to restore normal leaflet pliability and mobility.
Here, we report a case of mitral valve repair with a bileaflet (decellularized) pericardial patch in a patient with a severe form of rheumatic mitral valve disease.
A 39-year-old woman with a history of rheumatic mitral valve disease and paroxysmal atrial fibrillation presented with progressive dyspnea on exertion. Her medical history was remarkable for previous successful open mitral commissurotomy.
1 - Preoperative echocardiography (0:00)
Transthoracic echocardiography demonstrated mild to moderate mitral regurgitation and severe mitral stenosis with a mean pressure gradient of 12.6 mmHg and a mitral area of 1.1 cm2. Left ventricular function was normal. Valve evaluation demonstrated typical features of rheumatic mitral valve disease: (recurrent) commissural fusion, mitral valve leaflet fibrosis and calcification, and fusion and fibrosis of the subvalvular apparatus and the ventricular surface of the mitral valve leaflets. Taking all these aspects into consideration, the patient was accepted for surgical mitral valve repair.
2 - Surgical valve analysis (0:19)
The procedure was performed through a median sternotomy and myocardial protection was achieved by antegrade warm blood cardioplegia. Surgical analysis revealed restriction of the P1-P2 segments with thickened, fibrosed and fused chordae tendineae. Furthermore, calcification of the P2 and severe fibrosation of the A3 segment were observed. Extensive, recurrent fusion of the posteromedial commissure was also present. In order to restore normal leaflet motion, secure sufficient area of leaflet coaptation, and ensure a durable repair, all these problems needed to be addressed.
3 - Release of the subvalvular apparatus (0:51)
Restriction of the P1-P2 segments was addressed by resecting the fibrotic and shortened primary chordae of these segments. The corresponding papillary muscle was further mobilized to relieve residual leaflet restriction.
4 - Posteromedial commissurotomy (1:09)
In our case, severe commissural fusion was seen at the posteromedial commissure. To restore sufficient mitral valve area, the commissure was incised several millimeters from the annulus, extending towards the mitral valve orifice. No commissural fusion of the anterolateral commissure was present.
5 - Patch augmentation of the A3 segment of the anterior leaflet (1:24)
Severe fibrosation of the A3 segment was readily identified during valve analysis. The fibrotic leaflet tissue needed to be resected and replaced to restore normal leaflet pliability and motion. First, the fibrotic tissue was resected. Then leaflet augmentation with a decellularized pericardial patch (CardioCel, Admedus Regen Pty Ltd., Perth, WA, Australia) was performed. The pericardial patch was implanted with a running 5-0 monofilament polypropylene suture. Due to the lack of support at the free edge of the P3 and A3 segment, 2 pairs of polytetrafluoroethylene neochords were implanted. Each end of the neochord was passed through the leaflet (2-3 millimeters from the free edge) twice. The length of each end was adjusted to bring the level of the leaflet free edge to the level of adjacent segments. Final corrections were made during the water test and the neochords were tied thereafter.
6 - Posterior leaflet patch reconstruction (2:46)
The severely fibrotic and calcific degenerated P2 segment – including the subvalvular apparatus – was first resected, all the way up to the mitral valve annulus. A second CardioCel pericardial patch was used to restore leaflet continuity, again using a running single 5–0 monofilament polypropylene suture. Two pairs of polytetrafluoroethylene neochords were implanted to provide support to the neo-free edge of the reconstructed part of the posterior mitral valve leaflet. The length of the neochords was adjusted during the water test.
7 - Final water test (3:52)
The appropriate size of the annuloplasty ring was based on the size of the body of the anterior mitral valve leaflet. An annuloplasty ring size of 34 was selected. The ring was implanted in a standard fashion. The final water test revealed no residual leakage.
8 - Predischarge echocardiography (4:04)
Intraoperative echocardiography demonstrated a good repair result with a mean pressure gradient of 3.5 mmHg, mild residual regurgitation, and good height of leaflet coaptation. The postoperative course was uneventful. Predischarge echocardiography (postoperative day 5) revealed no residual mitral regurgitation and a mean pressure gradient of 3.2 mm Hg. The patient was discharged on postoperative day 6.
Surgical mitral valve repair in rheumatic mitral valve disease remains technically challenging. Often a combination of several techniques is needed to restore leaflet pliability and surface of coaptation in order to ensure a durable valve repair. Recent studies have demonstrated that valve repair in rheumatic mitral valve disease is feasible in 23-40% of cases . Furthermore, the long-term results on durability have improved and justify valve repair whenever it can be considered technically feasible .
Several factors intrinsic to the underlying disease and the subsequent repair predispose to recurrent valve dysfunction. In particular, pericardial patch techniques are progressively utilized to restore mitral valve leaflet function. Several options – including untreated/glutaraldehyde-treated autologous or bovine pericardium - are currently in use. Previously, unsatisfactory results have been reported because untreated/glutaraldehyde-treated autologous pericardium and bovine pericardium are prone to degeneration and/or calcification . We currently utilize pre-treated decellularized bovine pericardium (CardioCel) in all cases of leaflet reconstruction or augmentation. In our experience, the early results are encouraging; however, more data on patch durability is needed.
- Dillon J, Yakub MA, Kong PK, Ramli MF, Jaffar N, Gaffar IF. Comparative long-term results of mitral valve repair in adults with chronic rheumatic disease and degenerative disease: is repair for "burnt-out" rheumatic disease still inferior to repair for degenerative disease in the current era? J Thorac Cardiovasc Surg. 2015;149(3):771–7; discussion 7-9.
PubMed Abstract | Publisher Full Text - Kim JB, Kim HJ, Moon DH, Jung SH, Choo SJ, Chung CH, et al. Long-term outcomes after surgery for rheumatic mitral valve disease: valve repair versus mechanical valve replacement. Eur J Cardiothorac Surg. 2010;37(5):1039–46.
PubMed Abstract | EJCTS Full Text - Kim GS, Lee CH, Kim JB, Jung SH, Choo SJ, Chung CH, et al. Echocardiographic evaluation of mitral durability following valve repair in rheumatic mitral valve disease: impact of Maze procedure. J Thorac Cardiovasc Surg. 2014;147(1):247–53.
PubMed Abstract | Publisher Full Text - Fukunaga N, Sakata R, Koyama T. Reoperative analysis after mitral valve repair with glutaraldehyde-treated autologous pericardium. Interact Cardiovasc Thorac Surg. 2017 Jun 21;
PubMed Abstract | ICVTS Full Text - Tomšič A, Schneider AW, Palmen M, van Brakel TJ, Versteegh MIM, Klautz RJM. Extensive infective endocarditis of the aortic root and the aortic-mitral continuity: a mitral valve sparing approach. Eur J Cardiothorac Surg. 2017 Jun 1;51(6):1100–1107.
PubMed Abstract | EJCTS Full Text
The Department of Cardiothoracic Surgery, Leiden University Medical Center has previously received an unrestricted research grant from Admedus Regen Pty Ltd., Perth, WA, Australia.
Authors
Daniella D. Bissessar, Anton Tomšič, Thomas J. van Brakel, Robert J.M. Klautz, and Meindert Palmen
Author Affiliations
Department of Cardiothoracic Surgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, Netherlands
Corresponding author
Anton Tomšič, MD,
Department of Cardiothoracic Surgery, Leiden University Medical Center, K6-S, PO Box 9600, 2300 RC Leiden, Netherlands
Phone: +31-71-5263445
Fax: +31-71-5266899
Email: a.tomsic@lumc.n
Keywords
© The Author 2018. Published by MMCTS on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
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