Objectives: To evaluate the long-term results of mitral valve repair in patients with mitral regurgitation caused by isolated posterior leaflet prolapse at Danang Hospital. Subjects and methods: A retrospective, descriptive study combined with a prospective study. Thirty two patients with chronic severe mitral regurgitation due to isolated posterior leaflet prolapse were treated by new surgical techniques in Danang Hospital from February 2010 to October 2017.
Trang 1EARLY AND LONG-TERM RESULTS OF MITRAL VALVE
REPAIR FOR MITRAL REGURGITATION DUE TO
ISOLATED POSTERIOR LEAFLET PROLAPSE
Tran Ngoc Vu*; Le Ngoc Thanh**
SUMMARY
Objectives: To evaluate the long-term results of mitral valve repair in patients with mitral regurgitation caused by isolated posterior leaflet prolapse at Danang Hospital Subjects and methods: A retrospective, descriptive study combined with a prospective study Thirty two patients with chronic severe mitral regurgitation due to isolated posterior leaflet prolapse were treated by new surgical techniques in Danang Hospital from February 2010 to October 2017 Preoperative, pre-discharge and follow-up findings were recorded Postoperative echocardiography was performed in all patients at predischarge and during clinical follow-up Late survival and freedom from adverse events including hemorrhage, endocarditis, reoperation, and residual severe mitral regurgitation were estimated by using the Kaplan-Meier survival analysis Results: Ages ranged from 12 to 68 years (mean 43.06 ± 15.78 years) According to New York Heart Association (NYHA) functional classification: 3.12% (1/32) of patients were in class I; 90.63% (29/32) were in class II; 6.25% (2/32) were in class III, and no patient was in class IV; 32 patients (100%) had severe mitral valve regurgitation (3+)
Twenty-six patients were treated by triangular resection of posterior leaflet; five patients by chordal replacement and one patient by both techniques Echocardiography was carried out in all patients before discharged from hospital; 96.88% of patients had no or mild regurgitation, and 3.12% of patients had moderate regurgitation (2+), no one had severe regurgitation; no in-hospital mortality Late mortality occurred in only one patient at 3 months after discharge because of severe heart failure The mean follow-up time of patients was 36.44 ± 26.09 months (from 3 to 94 months), all the 31 surviving patients were in NYHA class I Echocardiographic examination during follow-up revealed that mitral insufficiency was none or mild (≤ 1+) in 100%
of patients No patient had moderate or severe mitral regurgitation Kaplan-Meier survival analysis estimates were 96.9 ± 3.1% for late survival and 96.9 ± 3.1% for freedom from recurrent severe mitral regurgitation at 7 years Conclusion: Mitral repair for mitral regurgitation due to isolated posterior leaflet prolapse is a feasible and safe procedure with an excellent surgical long-term outcomes
* Keywords: Mitral valve; Isolated posterior prolapse mitral regurgitation; Mitral repair
INTRODUCTION
Mitral regurgitation (MR) is a very common
valvular disease Surgical treatment
improves patients' prognosis and quality
of the life [1] Posterior leaflet prolapse
is the most common lesion seen in degenerative mitral valve disease [2] Quadrangular resection, first proposed by
* Danang Hospital
** Hanoi E Hospital
Corresponding author: Tran Ngoc Vu (tngocvu@gmail.com)
Date accepted: 30/08/2018
Trang 2Alain Carpentier, has progressed to
become the gold standard modality to
repair posterior leaflet prolapse Although
this “resection technique” is safe,
reproducible, and offers favorable
long-term results, it presents major drawbacks
[3] Tri-angular leaflet resection of the
mitral valve produces durable results and
can be safely and efficiently performed
with minimal morbidity and mortality [4]
The use of artificial chordae to correct the
leaflet prolapse restores the normal
anatomy and physiology of the mitral
valve, thus producing an optimal surface
of coaptation [3] Our research aims to:
Evaluate the long-term results of mitral
valve repair in patients with mitral
regurgitation caused by isolated posterior
leaflet prolapse
SUBJECTS AND METHODS
1 Subjects
This study was carried out at Danang
Hospital from February 2010 to October
2017 Thirty-two consecutive patients with
chronic severe MR due to isolated
posterior leaflet prolapse underwent mitral
valve repair Patients with tricuspid
insufficiency were included
2 Methods
Retrospective combined with prospective
study, cross-sectional descriptive analysis
without control group
* Preoperative assessment:
Clinical assessment by NYHA class
Severity of MR was defined by Doppler
echocardiography (grade 1+, 2+, 3+, and
4+) by semiquantitative method The etiology
of MR was identified by surgeon during operation
* Surgical indications:
Indications for mitral surgery, as expressed in the guidelines, were based
on levels of evidence B [5]
* Surgical technique:
All operations were performed through
a full median sternotomy and under cardio-pulmonary bypass with ascending aortic and bicaval canulation and aortic cross-clamping for the entire valve repair time Myocardial protection was accomplished with intermittent cold blood cardioplegia given down the aortic root
The mitral valve was exposed through transseptal or left atrial approach The mitral valve was then inspected in detail and the prolapsed area was identified We used the triangular resection and chordal replacement techniques or combined both techniques for repair the prolapsed area
of posterior leaflet Finally, a complete flexible ring or a pericardial band was applied for mitral annuloplasty
* Postoperative assessment:
All patients had a transthoracic echocardiography study before hospital discharge
Follow-up investigations included clinical examination, electrocardiography, and Doppler echocardiography Doppler echocardiography was carried out every
3 months in the first postoperative year and every 6 months thereafter Results were recoded at the latest follow-up examination
Trang 3* Statistical analysis:
Descriptive statistics are reported as
the mean ± standard deviation for
continuous variables and compared by a
student t-test or Wilcoxon Signed Ranks
test Categoric variables are reported as
frequencies and percentages and were compared using Chi-square tests For statistical analysis, the statistical software SPSS version 22.0 for Windows was used, and p value less than 0.05 was considered statistically significant
RESULTS
1 Preoperative and intraoperative characteristics
Table 1: Preoperative baseline characteristics
NYHA functional status:
There were 24 men (75.0%) and
8 women (25.0%).Mean age ranged from
12 to 68 years (mean age 43.06 ± 15.78
years) The patients were of NYHA
functional class I 3.12%, class II 90.63%,
class III 6.25%, and no patient in class IV
The cardiothoracic ratio ranged from 0.45
to 0.66 (mean 0.57 ± 0.07) 100% of
patients had severe MR (grade 3+) on
Doppler echocardiograhy
* Etiology of MR:
The most frequent cause of non-ischemic structural MR was degenerative mitral valve disease (24 patients = 75.0%), and low incidence was rheumatic valvular disease (1 patients = 3.12%) Other etiology was endocarditis (4 patients
= 12.5%) and congenital (3 patients
= 9.38%)
Trang 4Table 2: Procedures
Table 2 describes the predominant repair technique for isolated posterior leaflet prolapse Triangular resection was the most common technique in our series (81.25%) and the annulus dilatation was treated with prosthetic ring remodeling annuloplasty in
31 patients (96.88%) Prosthetic ring sizes ranged from 26 to 32 (mean 29.42 ± 1.57) Chordal replacement in 15.63% and one patient having a combination of both leaflet resection and chordal implanted (3.13%) Concomitant operation performed was tricuspid valve repair in 6 patients (18.75%)
2 Before discharge results
Table 3: Early postoperative results
MR severity:
The mean hospital stay was 11.03 ± 3.57 days (range 6 - 22 days) The mean intensive care unit stay was 2.16 ± 1.25 days (range 1 - 6 days) The postoperative complications were low in our series
Trang 5All patients had undergone a postoperative pre-discharge transthoracic echocardiography, 96.88% of patients had no or mild regurgitation and 3.12% of patients had moderate regurgitation (2+), no one had severe regurgitation; no in-hospital mortality
3 Long-term results
Table 4: Long-term postoperative results
NYHA class:
< 0.05
Electrocardiographic findings:
< 0.05 Echocardiographic findings:
< 0.001
Grade MR on echocardiography:
< 0.001
(LVESD: Left ventricular end-systolic diameter; LVEDD: Left ventricular end-diastolic diameter; LAD: Left atrial diameter; SPAP: Systolic pulmonary artery pressure; EF: Ejection fraction; MR: Mitral regurgitation)
Table 4 summarizes the preoperative and long-term postoperative data of mitral valve repair The mean follow-up period of patients was 36.44 ± 26.09 months (from 3
to 94 months) No patient need to reoperation, no patient had anticoagulation related hemorrhage and endocarditis during the follow-up Late mortality occurred in only one patient at 3 months after operation because of severe heart failure due to severe recurrent MR All the 31 surviving patients were in NYHA class I Echocardiographic examination during follow-up revealed that mitral insufficiency was none or mild (≤ 1+)
in 100% of patients
Trang 6DISCUSSION
Mitral regurgitation is a very common
valvular disease Mitral repair is a method
of choice in treatment of significant MR
[1] Mitral valve repair techniques were
pioneered by Alain Carpentier with a rigid
annuloplasty ring in his publication the
“French Correction” [6] Surgical techniques
have continuously developed over the
past five decades [7] There are many
techniques to correct the prolapsing
leaflet, and there has been a move away
from the traditional posterior leaflet
resection (quadrangular resection/sliding
technique) to leaflet preservation
techniques with Gore-Tex neochordae [8]
The classic quadrangular resection technique
became the gold standard for isolated
posterior leaflet prolape This method has
several disadvantages like lack of height
of leaflet coaptation, deformation of the
sub-annular region of the left ventricle and
the risk of king-king of the circumflex
artery Triangular resection reduced
some disadvantages of quadrangular
resection In our practice, no quadrangular
resections were employed We relied
mostly on triangular resections of posterior
leaflet (81.25%) It is quicker and easier
to perform than standard quadrangular
resection Chordal replacement has also
been used occasionally to correct the
prolapse of the posterior leaflet (15.63%)
On the other hand, in the case, after the
greatest area of prolapse is resected,
there still remains areas of chordal
elongation where the posterior leaflet
requires additional artificial chordae
support (3.12%) George K.M et al [9]
reported that triangular resection represents
a simple and effective technique for the management of segmental posterior leaflet prolapse Ibrahim M et al [10] concluded that the clinical outcomes of artificial chordae for the repair of the mitral valve are comparable with classical techniques and it may have some physiological advantages and provides a good long-term results
Our study demonstrates that the both techniques (triangular resection and neochord replacement) for isolated posterior leaflet prolapse repair had excellent results with 100% of patients having none or mild (≤ 1+) MR and no adverse complications after operation
CONCLUSION
Isolated posterior leaflet prolapse is the most common lesion seen in degenerative mitral valve disease Triangular posterior leaflet resection is an easy, effective and durable method for correcting posterior leaflet prolapse Artificial chordal replacement has been shown to be effective and durable outcomes too The combination of triangular resection and annuloplasty is
an excellent option for mitral valve repair
in most patients with isolated posterior leaflet prolapse
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