Even though our patient had rheumatic mitral regurgitation, which often requires valve replacement, she underwent successful valve repair. Intraoperative transesophageal echocardiography demonstrated the absence of any residual mitral regurgitation and the patient did well postoperatively. Post valve repair, she was maintained on medications to control her atrial arrhythmia, and on warfarin, as prophylaxis for emboli. She was enrolled in a post heart surgery exercise rehabilitation program, became asymptomatic, and resumed her normal lifestyle.
Follow-up echocardiography showed minimal mitral regurgitation, minimal mitral stenosis, and well maintained left ventricular function.
Fundamental steps in mitral valve repair surgery
This is a diagram of the fundamental steps in mitral valve repair. Figure A demonstrates the flail mid portion of the posterior mitral leaflet with ruptured chordae tendineae that is excised, in figure B, the valve annulus is reapproximated; and in figure C, the valve leaflet is reapproximated and the repair is buttressed with an annuloplasty ring.
Valve repair surgery
The following mitral valve surgery is presented through the courtesy of Drs. Robert hall and Denton Cooley and was carried out at the Texas Heart Institute.
This case will demonstrate the valve repair, or valvuloplasty, technique in a patient with a redundant, or floppy, mitral valve.
As it is a floppy valve, it is quite favorable for a valve repair, rather than a valve replacement. It is a very redundant leaflet, the posterior leaflet is especially redundant. There is a portion being excised... and now we’ll repair that defect with a 3.0 suture, and we are repairing the posterior leaflet with interrupted sutures.
A valvuloplasty is superior in many ways to the use of a total valve prosthesis, as these patient do not require anticoagulation postoperatively.
The next thing we will do is measure the annuli to see what size ring we are going to employ. The sutures go right into the annuli, right into the whitish tissue of the valve and the pink tissue of the atrium. The purpose of the ring is first to reduce the circumference of the annuli and, therefore, reinforce the repair of the posterior leaflet, so there is no undue stress put on that row of interrupted sutures. And there you see the ring completely encircling the annulus. It is a very redundant valve, but I believe we’ll have good competence after.
Valve replacement surgery
The following mitral valve surgery is presented through the courtesy of Drs. Robert hall and Denton Cooley and was carried out at the Texas Heart Institute.
The patient’s valve is severely redundant, or floppy, and requires mitral valve replacement.
There is that big, sort of floppy, valve, an enormous valve… and there is calcium in that posterior annuli. In many instances we try to preserve the posterior leaflet and valve replacement, but it may not be very practical here.
Alright, let’s take the anterior leaflet… knife, please. You can see how elongated the chordae tendineae are…
There is the anterior leaflet now… Let’s see what we can do with that posterior leaflet. Let’s take most of the posterior leaflet out. More or less piecemeal…
We’ll use a St. Jude bileaflet prosthesis. This is a bileaflet valve made of pyrolytic carbon, which is a very durable material and is moderately thromboresistant, almost like Teflon in that regard. Alright…