Excision Of Leaflets Research Articles

Mitral Leaflet Shortening as an Ancillary Procedure in Obstructive Hypertrophic Cardiomyopathy

BackgroundMitral leaflet elongation is common in hypertrophic cardiomyopathy (HCM), contributes to obstructive physiology, and presents a challenge to the dual surgical goals of abolition of outflow gradients and abolition of mitral regurgitation. Anterior leaflet shortening, performed as an ancillary surgical procedure during myectomy, is controversial. MethodsThis was a retrospective study of all patients undergoing myectomy from January 2010 to March 2020, with analysis of survival and echocardiographic results. The study compared outcomes of patients treated with myectomy and concomitant mitral leaflet shortening with patients treated with myectomy alone. Over this time, the technique for mitral shortening evolved from anterior leaflet plication to residual leaflet excision (ReLex). ResultsMyectomy was performed in 416 patients aged 57.5 ± 13.6 years, and 204 (49%) patients were female. Average follow-up was 5.4 ± 2.8 years. Survival follow-up was complete in 415 patients. Myectomy without valve replacement was performed in 332 patients, of whom 192 had mitral valve shortening (58%). Mitral leaflet plication was performed in 73 patients, ReLex in 151, and both procedures in 32. Hospital mortality for patients undergoing myectomy was 0.7%. At 8 years, cumulative survival was 95% for both the myectomy combined with leaflet shortening group and the myectomy alone group, with no difference in survival between the 2 groups. There was no difference in survival between the anterior leaflet plication and ReLex groups. Echocardiography 2.5 years after surgery showed a decrease in resting and provoked gradients, mitral regurgitation, and left atrial volume and no difference in key variables between patients who underwent ancillary leaflet shortening and patients who underwent myectomy alone. ConclusionsThese results affirm that mitral shortening may be an appropriate surgical judgment for selected patients.

Efficacy of Intraventricular Sponge Placement to Capture Debris in Aortic Valve Replacement.

Objective: Surgical aortic valve replacement (SAVR) carries the known risk of shedding debris into the left ventricle during valve leaflet excision and annulus debridement. Embolization of this debris may have devastating effects for the patient. Although surgeons have developed methods to mitigate this risk, no data exist as to their efficacy. Herein, we present the first study that evaluates the efficacy of a technique for capturing debris during SAVR. Methods: Our group conducted a prospective case series of 20 patients who underwent SAVR using the insertion of an intraventricular surgical sponge prior to valve leaflet excision and annulus debridement to capture debris. Surgical sponges were grossly, radiographically, and histologically examined for the presence of cellular and acellular debris to determine the efficacy of this technique. Results: Of the 20 surgical sponges analyzed, 15 specimens (75%) registered positivity for cellular and/or acellular debris. Seven sponges (35%) were grossly positive, 15 sponges (75%) were radiographically positive, and 4 sponges (20%) were histologically positive for calcified debris on examination. Conclusions: This is one of the few studies to objectively evaluate a method used to capture debris in SAVR procedures. Our results demonstrate a high frequency of debris captured within intraventricular surgical sponges and confirms the efficacy of this technique. While these data are promising, numerous additional approaches exist to capture debris, and a best practice standard should exist across the specialty. In addition, this study does not address the clinical outcomes associated with this technique. To these ends, additional data and multicenter collaboration are required.

Outcomes of complete mitral valve excision and replacement with tilting disc (TTK Chitra) valve for rheumatic mitral valve stenosis

Background: Mitral valve (MV) disease is one of the earliest diseases of the heart, and rheumatic MV disease is one of the first discovered in the world dating back to the 19th century. Rheumatic heart disease (RHD) is declining in other countries, but it is still prevalent in the rural parts of India especially in lower economic group. In our hospital, we have operated 50 cases of rheumatic mitral stenosis for whom mitral valve replacement (MVR) with tilting disc (TTK Chitra valve) was done. Most of the MV cases have MV score >12 and the subvalvular apparatus was severely affected. In all the cases we have operated, we have excised complete valve and no posterior leaflet preservation or chordal tethering and repair was done. Objectives of the study: To study MVR outcomes with tilting disc TTK Chitra valve and to compare pre- and postoperative valve gradient across tilting disc prosthetic valves and also study the left ventricular (LV) dimensions pre and post MVR and to study ejection fraction (EF) pre and post valve replacement and complications arising from posterior leaflet excision. Materials and Methods: Fifty patients with chronic RHD Chronic Rheumatic heart Disease (CRHD) with severe mitral stenosis were taken up for the study who were operated in this department from May 2016 to April 2019. All the patients were evaluated with 2D echo, electrocardiogram, and coronary angiogram (when they were >35 years old). Results: Out of 50 patients operated in our hospital, 34 were females, that is, 68% of the patients, and 16 patients were males, that is, 32%. As per age, 20 patients were between 41 and 50 years of age, that is, 40% belonged to 41–50 years of age; 39 patients were below 50 years, that is, 78% of patients were below 50 years; 4% are below 20 years; and 22% were above 50 years. As per the combined age and sex ratio also among both males and females, most Mitral Stenosis (MS) presumed below 50 years only. As per the valve area, the most common valve by preoperative echo was 66% below and equal to 1 cm[2] by Pressure half time (PHT) and Planimetry. About 60% of the patients had preoperative EF of more than 55% and less than 10% had between 36% and 40%. Preoperatively, 40% of the patients had severe pulmonary arterial hypertension (PAH), 30% of the patients had moderate PAH, and 30% of the patients had mild PAH. All these patients had been operated for MV where posterior leaflet was excised and no subvalvular apparatus was conserved and no chordal repair was done, but apparently no postoperative LV dysfunction was found in these patients. All these patients had taken up for MVR and TTK Chitra valve between 27 and 31 was used. In 70% of the patients, 29 and 31 TTK Chitra valve was used. This study is based on the echocardiographic analysis of the preoperative mean gradient across MV and postoperative mean gradient across MV which shows a considerable, comparable, and acceptable mean gradient postoperatively. Conclusion: Whenever rheumatic mitral stenosis is present, complete valve can be reasonably excised without even sparing or preserving the subvalvular apparatus and it does not affect the EF and LV function. Native tilting disc valve, that is, TTK Chitra valve, can be safely used and it can give comparable results with the recent generation valves. Better outcomes are encountered with 29-mm size and above valves. Pulmonary artery hypertension decreases significantly if mitral stenosis is operated regardless of the advancement of disease process. There is no significant change in the LV parameters, and pre- and postoperatively EF remained the same.

A Novel Method of Leaflet Reconstruction After Triangular Resection for Posterior Mitral Valve Prolapse

Triangular leaflet resection to treat posterior mitral valve prolapse is expedient, sufficient, and durable in eliminating redundant myxomatous tissue and restoring normal leaflet coaptation. After triangular resection and suture reconstruction, mitral scallop height is decreased to a degree commensurate with the area of tissue resected. There are instances however, when excessive bulk of the remaining posterior leaflet may persist, predisposing to systolic anterior motion of the anterior mitral leaflet. We propose a novel adjunctive measure to normalize posterior leaflet height during suture reconstruction by ventricularizing what would otherwise have become the new tip of the posterior mitral leaflet. We have found that ventricularization of the leaflet edge during reconstruction obviates the need for excessive mitral leaflet resection, resulting in a symmetric and mobile neo-free edge that are capable of contributing to a robust zone of coaptation.

Acute Valvular Regurgitation

Acute severe valvular regurgitation is a surgical emergency, but accurate and timely diagnosis can be difficult. Although cardiovascular collapse is a common presentation, examination findings to suggest acute regurgitation may be subtle, and the clinical presentation may be nonspecific. Consequently, the presentation of acute valvular regurgitation may be mistaken for other acute conditions, such as sepsis, pneumonia, or nonvalvular heart failure. Although acute regurgitation may affect any valve, acute regurgitation of the left-sided valves is more common and has greater clinical impact than acute regurgitation of right-sided valves. Data to guide appropriate management of patients with acute regurgitation are sparse; there are no randomized trials, and much of the literature describes either small series or the experiences of specific centers. Despite these limitations, the available data are sufficient to allow identification of general principles as well as development of applicable guidelines from both the American College of Cardiology/American Heart Association and European Society of Cardiology. The guidelines recommend valve surgery for symptomatic patients with aortic or mitral regurgitation, including those with acute regurgitation.1–3 The data and guidelines emphasize overarching clinical principles, including the need for a high clinical suspicion of acute regurgitation, timely use of echocardiography, and, in the majority of patients, rapid progression to surgery. Causes of acute regurgitation overlap with causes of chronic regurgitation and vary depending on the valve affected (Table 1). Endocarditis may affect either the aortic or mitral valve, whereas other causes are unique to the specific valve involved. The majority of causes of acute regurgitation present as an acute or subacute event. However, acute regurgitation can occur in patients with chronic regurgitation, when regurgitant severity is exacerbated by factors such as coronary ischemia, chordal rupture, or leaflet perforation from endocarditis. Acute regurgitation of either the aortic or mitral valve may result from procedural …

Modification of the Bentall operation using the proximal double sewing technique without excision of leaflets

We present a report on reinforcement of the proximal anastomosis during the Bentall operation. The aortic wall was excised with a 5-mm remnant, and aortic valve leaflets were preserved. Interrupted horizontal mattress sutures (2-0 Polyestel) reinforced with pledgets were placed. The composite graft was placed at the intraannular position inside of the preserved leaflets. The aortic valve leaflets were then pasted to the sewing cuff with fibrin glue. A running suture with 4-0 monofilament was placed between the remnant of the aortic wall and the peripheral side of the sewing cuff wrapped with native aortic valve leaflets.

Implantation of a mechanical valve in a previously implanted mitral bioprosthetic orifice in a patient with mitral bioprosthetic failure

Complete removal of a previously implanted dysfunctional mitral bioprosthesis could result in extensive damage. Therefore, a 66-year-old female patient with a deteriorated mitral bioprosthesis had leaflet excision, and a "new" mechanical valve was sewn onto the previously implanted bioprosthetic sewing cuff. On postoperative echocardiography, the implanted valve had good hemodynamic performance with no paravalvular leakage. The patient's clinical condition improved after surgery.

Bicuspidization of the Tricuspid Valve for the Treatment of Posterior Leaflet Endocarditis: A Case Report

Patients who require surgical therapy for the treatment of tricuspid valve regurgitation can avoid undergoing tricuspid valve replacement if valve-sparing repair techniques are employed. Tricuspid valvular endocarditis frequently requires valvectomy, leaving the right side of the heart and pulmonary system vulnerable to unregulated blood flow. We present a case of complete posterior leaflet excision and plication of the involved portion of the tricuspid annulus, which resulted in "bicuspidization" of the valve, for the treatment of tricuspid valve endocarditis localized to the posterior leaflet.

Surgical management of severe truncal insufficiency: experience with truncal valve remodeling techniques

Background. Truncal valve insufficiency has been a significant short- and long-term risk factor for repair of truncus arteriosus. Recent reports have documented the virtues of truncal valve repair. The purpose of this report is to review our experience with truncal valve repair and illustrate our techniques. Methods. Between 1995 and 2000, 8 patients had interventions for severe truncal valve insufficiency at primary repair (3 patients) or in conjunction with conduit replacement (5 patients). One neonate had truncal valve replacement at initial repair early in the experience. The other 7 patients had truncal valve repair, 3 by valvar suture techniques. The remaining 4 patients had leaflet excision and annular remodeling in 3 (coronary reimplantation was required in 2) and commissure resuspension in 1 patient. Results. Trivial to mild truncal valve insufficiency is present in the patients who had leaflet excision and annular remodeling (n = 3) and commissure resuspension (n = 1). Of the 3 patients who had valvar suture truncal valve repair, there was one death and 2 patients required acute valve replacement. The 7 survivors are doing well 1 month to 6 years postoperatively. Conclusions. Truncal valve repair by valvar suture techniques has not been successful in our practice. Truncal valve remodeling by leaflet excision and reduction annuloplasty is an effective method for truncal valve repair. When leaflet excision of a coronary sinus of Valsalva is required, coronary artery translocation can be accomplished.

Systolic anterior motion of the mitral valve after mitral valve repair without a ring

We report a case of systolic anterior motion of the mitral valve after mitral reconstruction without a semirigid mitral annular ring. A 56-year-old man with mitral regurgitation due to ruptured chordae tendineae underwent mitral valve reconstruction by replacement of chordae tendineae, leaflet excision, and suture annuloplasty without an annular ring. Postoperatively, left ventricular outflow tract obstruction developed and echocardiography revealed systolic anterior motion of the mitral valve. These findings disappeared after medication with a β-blocking drug.