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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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