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Rivista di Chirurgia Cardiaca, Vascolare e Toracica

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The Journal of Cardiovascular Surgery 1999 April;40(2):177-81


lingua: Inglese

Expanding the use of ­total ­mitral ­valve pres­er­va­tion in com­bi­na­tion ­with implan­ta­tion of the Car­bo­Medics heart ­valve pros­thesis

Aagaard J., Andersen U. L., Lerbjerg G., Andersen L. Ib.

From the Depart­ment of Car­di­oTh­o­racic and Vas­cular Sur­gery Odense Uni­ver­sity Hos­pital, Odense, Den­mark


Back­ground. Pres­er­va­tion of the ­mitral ­valve and sub­val­vular appa­ratus was intro­duced ­into the ­clinic in the ­early six­ties, but for two ­decades the stan­dard tech­nique for ­mitral ­valve replace­ment ­included exci­sion of ­both leaf­lets and ­their ­attached ­chordae ten­di­neae. ­Lately, ­increased ­emphasis has ­again ­been ­placed on reten­tion of the ­mitral sub­val­vular appa­ratus ­during ­valve replace­ment ­because of its ­role on ­left ven­tric­ular func­tion.
­Methods. We ­have pre­served the val­vular and sub­val­vular ­mitral appa­ratus, ­when pos­sible, in con­nec­tion ­with ­mitral ­valve replace­ment ­during the ­last ­seven ­years and the ­present inves­ti­ga­tion (­partly pros­pec­tive and ­partly ret­ro­spec­tive) was ­done ­with the aim of ­making up the ­results of our ­mitral pres­er­va­tion tech­nique. In the ­period ­between Jan­uary 1990 and ­December 1995, 30% of the ­patients who under­went ­mitral ­valve replace­ment had com­plete reten­tion of all ­mitral ­tissue. In 1996, the per­centage had ­increased to 50, and ­during the ­first ­seven ­months of 1997, 70% of the ­patients had com­plete reten­tion of all ­mitral ­tissue. ­Since Jan­uary 1997, we ­have exclu­sively ­used the Car­bo­Medics ­mitral ­heart ­valve pros­thesis. A ­total of 56 ­patients ­were iden­ti­fied to ­have had a Car­bo­Medics ­heart ­valve pros­thesis ­implanted. ­There ­were 33 men and 23 ­women ­with a ­mean age of 63 ­years, ­range 23-77 ­years. Cor­o­nary ­bypass was a con­com­i­tant pro­ce­dure in 22 ­patients. In ­seven ­patients, ­both the ­mitral and ­aortic ­valves ­were ­replaced. A ­severely ­altered ­valve ­with thick­ened and or cal­ci­fied leaf­lets, ste­notic leaf­lets, or short­ened, ­retracted and thick­ened ­chordae ten­di­neae ­were not a con­tra­in­di­ca­tion for the pro­ce­dure. Cal­ci­fied ­plaques ­were ­removed. Adhe­sion ­between ante­rior and pos­te­rior leaf­lets was ­treated ­with ­sharp dis­sec­tion. ­Valve and sub­val­vular ­tissue ­were pre­served. The leaf­lets ­were ­reefed ­within the ­valve-­sutures and com­pressed ­between the ­sewing ­ring and the ­native ­annulus ­when ­implanting the ­valve pros­thesis. ­Chordal ten­sion on the ven­tricle was ­thereby main­tained and the ­chordae ­pulled ­away ­from the ­valve ­effluent. Ech­o­car­di­og­raphy ­with meas­ure­ment of ejec­tion-frac­tion was per­formed pre­op­er­a­tively ­during the post­op­er­a­tive ­course in ­case of car­diac prob­lems and on a rou­tine ­basis 1 ­month ­after sur­gery and at var­ious inter­vals ­when the ­patient was ­seen in the out­pa­tient ­clinic. ­Left ven­tric­ular out­flow ­tract gra­dients ­were meas­ured ­during the post­op­er­a­tive ­course in ­case of car­diac prob­lems and rou­tinely 1 ­month post­sur­gi­cally.
­Results. ­Five ­patients ­died in the post­op­er­a­tive ­period and one ­patient had tran­sient neu­ro­log­ical symp­toms. In ­none of the ­patients was ­death or tran­sient neu­ro­log­ical symp­toms a con­se­quence of the reten­tion of ­mitral leaf­lets ­with sub­val­vular appa­ratus. The ­remaining 51 ­patients ­were all ­alive at ­follow-up. Post­op­er­a­tive ech­o­car­di­og­raphy dem­on­strated a pre­served ­left ven­tric­ular func­tion and a ­left ven­tric­ular out­flow ­tract ­without obstruc­tion.
Con­clu­sions. We ­find ­that the ­described tech­nique in com­bi­na­tion ­with implan­ta­tion of a Car­bo­Medics ­heart ­valve pros­thesis is ­very ­useful ­even in ­patients ­with a ­severely ­altered ­valve, ­when pre­serving the ­mitral leaf­lets ­with sub­val­vular appa­ratus ­during ­valve replace­ment. The tech­nique is ­without pro­ce­dure ­related com­pli­ca­tions and pre­serves ­left ven­tric­ular func­tion ­without ­obstructing the ­left ven­tric­ular out­flow ­tract.

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