Microsizing Using Inside Suture Placement. A Simple and Versatile Technique for Precision Adjustment of Ring Annuloplasties
DOI:
https://doi.org/10.1532/HSF98.20121068Abstract
Introduction: A new and simple technique for eliminating residual leaks during mitral annuloplasty, called microsizing, is described.
Methods: Microsizing is performed by moving one or more annuloplasty sutures from the outside to the inside of the prosthetic ring. This maneuver advances discrete segments of the annulus toward the opposing leaflet by a distance equal to the thickness of the ring (approximately 3 mm). Microsizing is a simple method for precision adjustment of annular shape and size to eliminate focal gaps, regardless of the cause.
Results: A series of 63 consecutive patients with moderate to severe mitral regurgitation (MR) were repaired over a 10 year period, all with intraoperative transesophageal echocardiography guidance. No patient required valve replacement (repair success rate 100%). Concomitant (non-mitral valve) procedures were performed in 53 patients (84.1%). Fifty patients (79.3%, Group 1) underwent successful repair using traditional suture placement in the prosthetic ring. Thirteen patients (20.6%, Group 2) had one or more sutures repositioned to the inside of the ring ("micro-sized") as a new strategy to eliminate residual leaks. Mean post repair MR grade was lower when microsizing was used (0.15 for Group 2 versus 0.30 for Group 1). No micro-sized patient experienced systolic anterior motion (SAM) or mitral stenosis. There were no repairs with greater than trace MR, late ring dehiscences, recurrent regurgitation, or reoperation in the entire series. There was one death (1.6%) in a non-micro-sized patient from intra-operative abdominal hemorrhage secondary to an IABP complication.
Conclusion: Microsizing is a simple variation of suture placement that allows custom shaping of the mitral annulus by advancing selected portions toward the opposing leaflet, eliminating gaps, and improving coaptation. This technique is safe, simple, and reproducible without causing stenosis, SAM, or late failure.
References
Auber S, Flecher E, Rubin S, Acar C, Ganjbakhch I. 2007. Anterior mitral leaflet augmentation with autologous pericardium. Ann Thorac Surg 83:1560-1.nCarpentier A, Deloche A, Dauptain J, et al. 1971. A new reconstructive operation for correction of mitral and tricuspid insufficiency. J Thorac Cardiovasc Surg 61:1-13.nCarpentier A. 1983 Cardiac valve surgery—the "French correction." J Thorac Cardiovasc Surg 86:323-37.nCarpentier AF, Lessana A, Relland JY, et al. 1995. The "physio-ring": an advanced concept in mitral valve annuloplasty. Ann Thorac Surg 60:1177-86.nde Varennes B, Chaturvedi R, Sidhu S, et al. 2009. Initial results of posterior leaflet extension for severe type IIIb ischemic mitral regurgitation. Circulation 19:2837-43.nDreyfus GD, Bahrami T, Alayle N, Mihealainu S, Dubois C, De Lentdecker P. 2001. Repair of anterior leaflet prolapse by papillary muscle repositioning: a new surgical option. Ann Thorac Surg 71:1464-70.nFrater RWM, Gabbay S, Shore D, Factor S, Strom J. 1983. Reproducible replacement of elongated or ruptured valve chordae. Ann Thorac Surg 35:14-26.nFrater RW, Vetter HO, Zussa C, Dahm M. 1990. Chordal replacement in mitral valve repair. Circulation 82(suppl):IV125-30.nGazoni L, Fedoruk LM, Kern JA, et al. 2007. A simplified approach to degenerative disease: triangular resections of the mitral valve. Ann Thorac Surg 83:1658-65.nGrossi EA, Galloway AC, Parish, MA, et al. 1992. Experience with twenty-eight cases of systolic motion after mitral valve reconstruction by Carpentier technique. J Thorac Cardiovasc Surg 103:466-70.nIbrahim MF, David TE. 2002. Mitral stenosis after mitral valve repair for non-rheumatic mitral regurgitation. Ann Thorac Surg 73:34-6.nKincaid EH, Riley RD, Hines MH, Hammon JW, Kon ND. 2004. Anterior leaflet augmentation for ischmic mitral regurgitation. Ann Thorac Surg 78:564-8.nKron IL, Green R, Cope JT. 2002. Surgical relocation of the posterior papillary muscle in chronic ischemic mitral regurgitation. Ann Thorac Surg 74:600-1.nLee KS, Stewart WJ, Lever HM, Underwood PL, Cosgrove DM. 1993. Mechanism of outflow obstruction following failed valve repair: anterior displacement of leaflet coaptation. Circulation 88(suppl):II24-9.nMaisano F, Torracca L, Oppizzi M, et al. 1998. The edge-to-edge technique: a simplified method to correct mitral insufficiency. Eur J Cardiothorac Surg 13:240-6.nMcGoon DC. 1960. Repair of mitral insufficiency due to ruptured chordae tendinae. J Thorac Cardiovasc Surg 39:357-62.nPerier P, Clausnizer B, Mistarz K. 1994. Carpentier "sliding leaflet" technique for repair of the mitral valve: early results. Ann Thorac Surg 57:383-6.nPerier P, Hohenberger W, Lakew F, et al. 2008. Toward a new paradigm for the reconstruction of posterior leaflet prolapse: results of the "respect rather than resect" approach. Ann Thorac Surg 86:718-25.nSauvage LR, Wood SJ, Berger KE, Campbell AA. 1966. Autologous pericardium for leaflet advancement. J Thorac Cardiovasc Surg 52:849-54.nVon Oppell UO, Mohr FW. 2000. Chordal replacement for both minimally invasive and conventional mitral valve surgery using premeasured Gore-Tex loops. Ann Thorac Surg 70:2166-8.n
