insufficiency in 27 of 29 patients who underwent valve reconstruction. Another factor that warrants consideration is that mitral valve reconstruction does not affect the subvalvular apparatus.
Callafiore AM, Sabina G, Gallina MD, et al. Mitral valve procedure in dilatedcardiomyopathy: repair or replacement? Ann Thorac Surg 2001; 71: 146-53.
*Lillehei CW, Levy MI, Bonnabeau Re. Mitral valve replacement with preservation of papillary muscles and chordae tendineae. J Thorac Cardiovasc Surg 1964;47:532-43.
Types of preservation
Partial Chordal Preservation: This technique involves
excision of the whole of the anterior leaflet and chordae tendinae with preservation of the posterior leaflet and associated subvalvular apparatus. The posterior leaflet is imbricated to the annulus. Alternatively, the leaflet is incised from edge to base at two or three points in between the scallops.
Puig technique
In this method both the anterior and
posterior leaflets of the mitral valve were divided into hemi leaflets. The resultant four pedicles were displaced under traction toward the left atrium and anchored between the mitral annulus and an implanted valvular prosthesis. Post operative Doppler echocardiography revealed evidence of LV remodeling in some of these patients, including lateral wall changes and a tendency of the LV cavity to return to its elliptical shape.
Puig LB, Gaiotto FA, Oliveira JL Jr, Pardi MM, Bacal F,Mady C, et al. Mitral valve replacement and remodeling of the left ventricle in dilated cardiomyopathy with mitral regurgitation: initial results. Arq Bras Cardiol. 2002;78(2):224-9.
Davids technique
The AML is incised at its base, 2-3 mm from its attachment. The incision is carried to both the sides and brought down centrally towards the free edge of the leaflet and a triangular segment of the AML is thus excised leaving the chordae attached to the remaining AML which is re-suspended to the mitral annulus by sutures used to secure the prosthetic valve. The PML with its chordae is left intact. In patients with myxomatous MR undergoing MVR, the chordae are shortened by imbricating the PML in the mitral annulus using the sutures used for prosthetic valve fixation. Alternatively, a part of the posterior leaflet is excised and reattached to the mitral annulus during fixation of the prosthetic valve. Advantages of the David technique are the maintenance of the chordae in their natural anatomic orientation, reduced risk of LVOTO and reduction in the bulk of leaflet tissue. David TE. Mitral valve replacement with preservation of chordae tendineae. Rationale and technical considerations. Ann Thorac Surg 1986; 41: 680-82.
Davids technique: (a) Normal Mitral valve. AML = anterior mitral leaflet, PML = posterior mitral leaflet (b)A triangular portion of the AML and a crescent of PML are excised.
Khonsari technique
After the AML is detached from the annulus between the two commissures, an ellipse of tissue is excised and the rim of the leaflet tissue containing the chordae is reattached to the anterior annulus (Khonsari I technique). If the leaflet is thick or calcified, it is divided into 2-5 chordal segments which are re-attached to the annulus (Khonsari II technique). The PML is retained completely and the redundant leaflet tissue is folded up into the annulus by passing the valve sutures through the annulus and bringing them through the leading edge of the leaflet tissue.
Sintek CF, Pfeffer TA, Kchamba TA, Khonsari SR. Mitral valve replacement: technique to preserve the subvalvular apparatus. Ann Thorac Surg 1995; 59: 1027-29.
Miki procedure
The mitral valve is carefully inspected. If the repair is ruled out then the anterior mitral
leaflet is pulled out carefully to inspect it.
An incision is then made few millimetres from the annulus along the anterior mitral ring.
The anterior leaflet is divided in the middle into anterior and posterior parts. The area in the middle is usually devoid of chordae and is excised in order to debulk the unnecessary tissue so that decent size prosthesis could be used. near the anterolateral and posteromedial commissures, respectively, with 2-0 pledget supported Ticron sutures that are taken from the ventricular to the atrial side of the leaflet and slightly away from the free margin of the annulus . ring along with the other valve sutures.
The anterior and posterior parts of the anterior leaflet are attached to the mitral ring,
These sutures are left untied and are subsequently taken through the prosthetic valve
The posterior leaflet is usually left as it is; on occasions it is incised in its middle
vertically a few millimetres shy off the annulus so that proper size prosthesis can be used. When taking sutures in the posterior leaflet annulus the free edge of the leaflet should be included so that the leaflet is compressed between the prosthetic ring and the annulus and does not impinge on prosthesis causing it to malfunction.
Miki S, Kusuhara K, Ueda Y, Komeda M, Ohkita Y, Tahata T. Mitral valve replacement with preservation of chordae tendineae and papillary muscles. Ann Thorac Surg.1988;45(1):28-34.
The mitral valve, dotted line is the area of incision in the anterior mitral leaflet
MIKI procedure
The anterior mitral leaflet is retracted by a hook. Chordae tendineae and papillary muscles of are shown. Dotted line is the chordae free portion to be excised
The anterior and posterior parts of the anterior leaflet are re-attached to the mitral ring near the anterolateral and posteromedial commissures
These sutures are left untied and are subsequently taken through the prosthetic valve ring along with the other valve sutures
Rose EA, Oz MC. Preservation of the anterior leaflet chordae tendineae during mitral valve replacement. Ann Thorac Surg 1994;57: 768-69.
Crossed papillopexy
After left atriotomy and adequate
exposure of the mitral valve, the anterior cusp is excised from the annulus and centrally spilt into two halves with its chordae tendineae complex, fixed to the opposite commissure by its medial end.
Otoni Moreira Gomes, Eros Silva Gomes; Geraldo Paulino Santana Filho; Jos Carlos Dorsa Vieira Pontes; Ricardo Adala Benfatti. New technical approach for crossed papillopexy in mitral valve replacement surgery: short term results. Rev Bras Cir Cardiovasc vol.20 no.3 So Jos do Rio Preto July/Sept. 2005
(B)
Schematic of mitral valve. In detaching the ellipsoid of tissue from the anterior leaflet, incision B is nearly straight and shorter than incision A. (AL=anterolateral commissure, PM=posteromedial commissure). (B) The strip to the annulus is reattached beginning at the posteromedial commissure in a counter clockwise direction with pledgeted mattress sutures that will also be used for the valve replacement.
Sasaki H , Ihashi K Eur J Cardiothorac Surg 2003;24:650-652
Problems of preservation
Mechanical- Valve obstruction( Low profile valve gives
better benefit), Relatively smaller sized valve is placed.
Thromboembolic Infective
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