A Novel Technique in Complex Primary Mitral Valve Repair using an Inverted Basal Triangular Posterior Leaflet Resection plus Neo Chordae in Severe Mitral Regurgitation

6278 

Cardiothoracic Resident Case Report Competition 

Ian Cummings (1), Periklis Perikleous (2), Ashok Narayasamy (3), Paul Modi (4), Ishtiaq Ahmed (5)

(1) St Thomas' Hospital, London, UK, (2) Bristol Royal Infirmary, Bristol, United Kingdom, (3) Royal Sussex County Hospital, Brighton, NA, (4) Liverpool Heart and Chest, WA142EF, United Kingdom, (5) Royal Sussex County Hospital, East Sussex, UK

Ian Cummings    -  Contact Me
St Thomas' Hospital

Periklis Perikleous    -  Contact Me
Bristol Royal Infirmary

Ashok Narayasamy    -  Contact Me
Royal Sussex County Hospital

Paul Modi    -  Contact Me
Liverpool Heart and Chest

Ishtiaq Ahmed    -  Contact Me
Royal Sussex County Hospital

Ian Cummings    -  Contact Me
Royal Sussex County Hospital, Brighton

Objective: To share a new technique in complex primary MV repair using an inverted basal triangular P2 resection plus neo-chordae in a symptomatic patient with severe MR secondary to P2 prolapse with chordal rupture.
Methods: A video presentation of a new technique of P2 prolapse MV repair. Pre-operative echo was scrutinised to establish the mechanism of MR and the risk of SAM as well as LV function and presence of TR. Operation: Median sternotomy approach. Bicaval cannulation instituted for CPB with access to the MV via Sondergaard's groove. The patient was cooled to 28 degrees. Annuloplasty sutures are placed initially to gain adequate exposure for valve inspection. The valve is fully assessed and interrogated for the assessment of the mechanism of MV regurgitation prior to choosing a repair technique. The Mitral Valve Repair technique chosen in this case combines posterior leaflet resection with neo-chordae. Basal inverted triangular resection is performed centred on the annular aspect of P2 leaflet to reduce P2 height. The leaflet is extended to its full length by temporarily anchoring the free margin of the leaflet to the anterior annulus with a sliding stay suture. This slight tension extending the leaflet aids with the resection of myxomatous tissue whilst preserving the main body of the MV leaflet tissue anteriorly. The width and height of the triangular resection can be adjusted accordingly and adapted to the requirements of the repair. Leaflet continuity is restored by approximating the 2 sides of the to base of the triangle at the annular leaflet attachment. In this case the leaflet height is reduced to 15mm as the sides of the triangle are approximated to the base of the triangle. A 5/0 Prolene running suture is used to close the defect and the deep cleft between P1 and P2 noted on the initial interrogation of the valve is also closed. We can now turn our attention to the neo-chordae. In this particular complex repair case three Goretex neo-chord to P2, A1 and A2 were inserted. This is followed by stabilisation of the annulus with a 36mm Annuloplasty Ring secured using CorKnot device. Saline test confirms a satisfactory repair and fine adjustment to the neo-chordae lengths complete the repair. The atrium is then closed, with a running suture. The heart is filled the X-clamp removed following de-airing techniques and the operation is completed. The patient came off CPB easily with no support and our post operative echo confirms absence of mitral regurgitation.
Results: We were able to achieve a stable MV repair using this newly described technique. Systolic anterior motion was avoided by reducing the leaflet height and a stable repair was achieved with no MR.
Conclusions: Our reproducible technique has inverted the classic French correction with the base of the triangle on the annular aspect of the leaflet attachment rather than the free margin. Using this technique, the main body of the leaflet is absent of a suture line and a stable repair is achieved. This reproducible technique can be added to the armamentarium of Primary MV repair achieving an excellent result whilst following the '10 commandments of MV repair' as described by the Cleveland Clinic group. We will continue to apply this technique in selected cases.

Adult Cardiac