Problems With Excess Mitral Leaflet After Repair: Possible Issues DuringRepair and Preservation of the Posterior Leaflet
Andrew Maslow, MD,* Feroze Mahmood, MD,§ Arun Singh, MD,† Nikola Dobrillovic, MD,† and
Athena Poppas, MD‡
3
THE NORMAL NATIVE MITRAL VALVE exists in adynamic balance involving all components of the appara-
tus to provide optimal coaptation during ventricular systole andminimal resistance to forward flow during ventricular diastole.The repaired myxomatous mitral valve has a similar balance,but with different annular and leaflet dimensions. Most com-monly, repairs include resection and reduction of the posteriorleaflet (PL) and a reduction annuloplasty, with or without repairof the anterior leaflet (AL). Green et al1 described the postrepair
L as restricted, acting to buttress the coapting AL. Function-lly, this repaired valve appears like a “unicuspid valve,” whichelies heavily on a normally functioning AL.1,2
Although not a new concept, there has been renewed interest inpreserving and repairing a prolapsing PL (“respect rather than resect”[RRR]).3-7 Proponents of RRR seek to treat the prolapse and return the
L toward a normal dimension, yielding a bileaflet valve, with aarger diastolic area and a larger coapting surface.3-7 Whether RRRinvolves preservation of the entire PL3,5-7 or a combination of resec-tion and preservation4 is decided case by case.
The authors present 3 patients in whom repair and preservation ofhe PL were performed. These 3 cases represent the authors’ initialxperience with the placement of new chordae to repair the PL. Twoatients developed systolic anterior motion (SAM) with left ventric-lar outflow tract obstruction (LVOTO) and mitral regurgitationMR), one immediately after cardiopulmonary bypass (CPB) and thether in the postoperative period. In the third patient, hemodynamicssessment showed mitral stenosis. For all 3 patients, the authorspeculate that the complications were the result of excess postrepaireaflet tissue below the annular plane.
CASE REPORTS
Case 1
An 80-year-old woman presented with myxomatous mitral valvedisease, severe MR, and a history of congestive heart failure and wasscheduled for valve repair. Transesophageal echocardiography (TEE)
From the Departments of *Anesthesiology, †Surgery and ‡Medicine,Rhode Island Hospital, Providence, RI; and §Department of Anesthe-siology, Beth Israel Deaconess Medical Center, Boston, MA.
Address reprint requests to Andrew Maslow, MD, 63 Prince Street,Needham, MA 02492. E-mail: [email protected]
immediately before CPB visualized a torn posterior (P) chordae, flail ofthe P3, and prolapse of P2 leaflet scallops (Fig 1). The AL appeared tohave myxomatous changes but did not prolapse. Risk assessment forpostrepair SAM was based on previously published data8 and includedratios of the systolic heights of the AL and PL (AL/PL; 0.9) and thedistance from the mitral coaptation point to the proximal ventricularseptum (CSEPT; 2.0 cm). Based on these data (AL/PL �1.4; CSEPT�2.5 cm), this patient was at risk for postrepair SAM and LVOTO.8
The patient underwent resection of P3 and repair of P2 using 4 newchordae attached to the posteromedial papillary muscle. A #28 Car-pentier Physio (Edwards Lifesciences, Irvine, CA) annuloplasty wasplaced. The TEE immediately after CPB visualized mobile AL and PLwithout MR (Video 1 [supplementary videos are available online]).There was no evidence of SAM of the mitral leaflets. Intraoperativevalvular hemodynamic data were not available.
The intraoperative course was uneventful. On postoperative day 2,the patient was short of breath. At this time, the heart rate was 85beats/min, systemic blood pressure was reported as 80/50 mmHg, andarterial oxygen saturation was 88% while receiving supplemental ox-ygen. Transthoracic echocardiography (TTE) visualized SAM withLVOTO and severe MR (Fig 2). Despite intravenous fluid and phen-ylephrine administration, SAM with LVOTO persisted; however, theMR had become moderate, and the patient’s symptoms were improv-ing. Low-dose metoprolol was administered and she was discharged onpostoperative day 12. Predischarge TTE showed SAM and moderateMR. Echocardiographic examination performed 1 year later showedmild MR and no SAM. The patient was asymptomatic.
Case 2
A 56-year-old man with bileaflet myxomatous mitral valve diseasepresented with increasing dyspnea and severe MR and was scheduledfor mitral valve repair. TEE examination immediately before CPBshowed bileaflet prolapse (Fig 3) and severe MR. Preoperative analysis(AL/PL 1.0) suggested that this patient was at risk for postrepair SAM.
The surgical procedure included partial resection of P2. The remain-ing scallops then were approximated to one another. The AL wasrepaired using new chordae. These were extended from the A1 and A2scallops to the anterolateral papillary muscle and from A3 and A2 tothe posteromedial papillary muscle. After noting that the PL stillprolapsed, new chordae were extended from the remaining scallops totheir respective anterolateral and posteromedial papillary muscles. A#34 Cosgrove (Edwards Lifesciences) annuloplasty ring was placed.
The patient was weaned from CPB. In the period immediately afterCPB, TEE showed SAM with LVOTO (Fig 4, Video 2). There wasmoderate-to-severe MR. Medical management included increasing theafterload and fluid administration. In a short time, the SAM, LVOTO,and MR resolved and the patient remained in stable condition. Mitralvalve hemodynamics showed a pressure half-time of 96 ms (mitralvalve area [MVA] 2.30 cm2). Postoperative offline analysis recorded a-dimensional planimetry of 2.1 cm2 (Tomtec software, Tomtec Imag-
ng System, Unterschleissheim, Germany). The postoperative period
ic and Vascular Anesthesia, Vol 27, No 1 (February), 2013: pp 92-97
Fig 1. Precardiopulmonary bypass images obtained during transesophageal echocardiography. The image in the upper left is a midesopha-
geal 4-/5-chamber view (ME 4/5C), and the image on the right is a midesophageal long-axis view (ME LAX). The posterior leaflet prolapses
above the annular plane. The 2 bottom images display 2 points of the systolic period, showing a flail portion of the posterior leaflet (PL). Because
this portion is below the left ventricular outflow tract (LVOT), it is the P3 scallop. The measured distance from the coaptation point to the
ventricular septum (C-Sept) is 2.0 cm and the ratio of the anterior leaflet (AL) to the posterior leaflet is 0.9. LA, left atrium; LV, left ventricle; PPm,
posterior papillary muscle; RA, right atrium; RV, right ventricle.
Fig 2. Three transthoracic echocardiographic images obtained during the postoperative period. The images are from the parasternal window
and show the left atrium (LA), aortic valve (AoV), and left ventricular outflow tract (LVOT). (A) This image was obtained during ventricular
diastole or filling. The arrow points to the anterior leaflet of the mitral valve. (B) This image was obtained during ventricular systole. The arrow
points to the anterior mitral leaflet, which lies in the left ventricular outflow tract. This is systolic anterior motion. (C) This image is a color
Doppler image of the image shown in B. The arrow points to color Doppler turbulence in the left ventricular outflow tract, which is evidence
of left ventricular outflow tract obstruction (LVOTO). At this time, there is also mitral regurgitation (MR).
e ante
94 MASLOW ET AL
was uneventful and the predischarge TTE depicted normal valve func-tion without SAM. Six months later, the TTE examination showedtrace MR and no SAM.
Case 3
A 64-year-old man with a history of mitral valve prolapse, increasingdyspnea, and severe MR presented for mitral valve repair. TEE imme-diately before CPB showed a flail middle (P2) scallop of the PL withruptured chordae (Fig 5). P1 and P3 also were found to have prolapsed.Preoperative analysis (AL/PL 2.5, CSEPT 3.5 cm) suggested that thispatient was at low risk for postrepair SAM and LVOTO.
After a limited resection of P2 was performed, the remaining pos-terior scallops were approximated. These scallops were noted to stillprolapse, and new chordae were extended from these scallops to their
Fig 3. Precardiopulmonary bypass images obtained during trans
4-chamber view (ME 4C), and the image on the right is a midesophag
point to the ventricular septum (C-Sept) is 2.0 cm and the ratio of th
valve; LA, left atrium; LV, left ventricle.
Fig 4. Three transesophageal echocardiographic images obtain
obtained from the midesophageal 4-chamber (ME 4C) and long-axis
ventricular outflow tract (LVOT). The midesophageal 4-chamber view
leaflet of the mitral valve, which lies in the left ventricular outflow tr
image is a color Doppler image of the mitral valve and left ventricul
Doppler turbulence in the left ventricular outflow tract, which is evid
points to the mitral regurgitation (MR). The rightmost image show
imaging of the left ventricular outflow tract. The peak velocity (VLVOT) is 4
consistent with dynamic outflow tract obstruction.
respective anterolateral and posteromedial papillary muscles. Aftercompletion of the procedure, a #32 St Jude Medical annuloplasty ring(St Jude Medical, St Paul, MN), adjusted to a saddle shape, was placed.After separation from CPB, TEE examination showed a stable repairwithout significant MR (Video 3). Quantitative hemodynamic assess-ment showed peak and mean gradients of 10 and 6 mmHg, respec-tively. Using the pressure half-time method, the MVA was calculated to be1.5 cm2 (Fig 6). Given the hemodynamic stability of the patient and theborderline increased transvalvular pressure gradients,9,10 the surgical pro-cedure was completed. Offline 3-dimensional planimetry (Tomtec soft-ware) performed after surgery showed an MVA of 1.6 cm2 (Fig 7).Additional 3-dimensional analysis showed a decrease in annular area, froma preoperative value of 7.7 cm2 to 2.6 cm2 immediately after CPB (Fig 8).Further analysis showed a tapering, or funnel-shaped, mitral apparatus
ageal echocardiography. The image on the left is a midesophageal
ng-axis view (ME LAX). The measured distance from the coaptation
rior leaflet (AL) to the posterior leaflet (PL) is 0.9 to 1.0. AoV, aortic
mediately after cardiopulmonary bypass. The 2 leftmost images
AX) windows show the left atrium (LA), left ventricle (LV), and left
obtained during ventricular systole. The arrow points to the anterior
his is systolic anterior motion (SAM). The midesophageal long-axis
tflow tract during ventricular systole. The arrow points to the color
of left ventricular outflow tract obstruction (LVOTO). Another arrow
ontinuous-wave Doppler image obtained during transgastric (TG)
esoph
eal lo
ed im
(ME L
was
act. T
ar ou
ence
s a c
.6 m/s (peak gradient [PGLVOT] 85 mmHg) and the Doppler profile is
ef
ilh
p
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septu
left v
(
95ISSUES AFTER POSTERIOR LEAFLET PRESERVATION
with a decrease in orifice area from 2.6 to 1.6 cm2 based on planimetricassessment from volumetric 3-dimensional data (Fig 8).
At 6-month follow-up, the pressure half-time was recorded as 129ms. Using these data, the MVA was calculated to be 1.7 cm2. At thistime, the patient was without symptoms and reported to have goodunctional capacity.
DISCUSSION
The authors have presented 3 cases of PL repair that werecomplicated by SAM in 2 cases and mitral stenosis in the third.Although SAM and a decrease in MVA are known to occurafter mitral valve repair, they are important to discuss in thecontext of PL preservation. This type of repair contrasts withthat described by Green et al,1 for which PL resection resultedn a functionally unicuspid valve. Preservation of the PL willeave a larger amount of tissue below the annular plane, per-aps increasing the risk of complications seen in the cases
Fig 5. Precardiopulmonary bypass images obtained during trans
4-chamber view (ME 4C), and the image on the right is a midesophag
The measured distance from the coaptation point to the ventricular
posterior leaflet is 2.5. Asc Ao, ascending aorta; LA, left atrium; LV,
Fig 6. Measurements of the mitral valve area (MVA) after mitral
(MV) obtained from the midesophageal long-axis view. Using the pressure
B) Offline measurement of the mitral valve area using 3-dimensional plan
resented.8,11 Although these cases are varied in the surgicalprocedure, together they highlight the complexity of repairingthe mitral valve, the interdependence of its components, and therisks of preserving too much leaflet. Also, it is unknownwhether previous echocardiographic predictors of postrepaircomplications are equally applicable to all kinds of repair.
Echocardiographic predictors of SAM after mitral valve re-pair have been reported for patients in whom the PL wasresected.8 A larger PL will coapt with the AL toward its base,leaving slack leaflet portions beyond the coaptation point.8
When these lie closer to the ventricular septum, the risk ofSAM is greater.8 Higher-risk patients are those with relativelyarger systolic heights of the PL compared with the AL (AL/PL
1.4) and a shorter CSEPT (�2.5 cm). Although not describedften, the predicted height of the PL after repair and where theoaptation point might lie may be very important.12,13 Gillinov
ageal echocardiography. The image on the left is a midesophageal
ng-axis view (ME LAX). The images show a flail posterior leaflet (PL).
m (C-Sept) is 3.5 cm and the ratio of the anterior leaflet (AL) to the
entricle; LVOT, left ventricular outflow tract.
repair. (A) Continuous-wave Doppler profile across the mitral valve2
esoph
eal lo
valve
half-time method (P1/2 time, P1/2t), the mitral valve area is 1.5 cm .
imetry. The mitral valve area is measured to be 1.6 cm2.
Sroimtf
aiaapteada
96 MASLOW ET AL
and Cosgrove13 suggested that the coapting height of the PLshould be �1.4 cm. Before mitral valve repair, it is crucialnot only to define the mitral pathology but also to assessleaflet heights or lengths and determine the risk of postrepairSAM. It stands to reason that if the PL is repaired (RRR), ie,an increased coapting height, then this would increase therisk of SAM. Although predictors of SAM have been de-scribed for patients undergoing PL resection, it is not knownwhether these data are applicable to cases in which the PL ispreserved.
Two studies have recognized the potential for SAM/LVOTO/MR when preserving the PL (RRR).4,5 To decrease therisk of SAM, the surgical procedure includes shortening thelength of the new chordae from the PL to the posteromedialpapillary muscle to decrease the systolic height of the PL. Thiseffectively would increase the AL/PL ratio and the CSEPT.4,5
Despite the recognized risk, cases of SAM still occur andrequire a return to CPB, when the surgeon further shortens thenew chordae to the PL and/or performs a septal myomec-tomy.4,5
Fig 7. Mitral inflow during ventricular diastole. The prominent pos-
terior leaflet (PL) is evident in the path (arrows) of ventricular inflow. AL,
anterior leaflet; AoV, aortic valve; LA, left atrium; LV, left ventricle.
Fig 8. Images from a 3-dimensional volume dataset before and af
as is tapering of the mitral area from the annular plane to the leaflet tips
leaflet.
Patients 1 and 2 were at increased risk of postrepair SAM asreflected by an AL/PL ratio �1.4 and/or a CSEPT �2.5 cm.8
Because these predictors are based on non-RRR cases, the riskof SAM in patients undergoing RRR may be greater becausethe PL is preserved. If, during the assessment before repair, therisk of SAM is considered high, then the proposed benefits ofRRR must be balanced against the risk of SAM/LVOTO/MR.If repair of the PL is planned, then the surgical procedureshould be geared toward moving the coaptation point awayfrom the LVOT by decreasing the length of the new chordae4,5
and/or placing a larger annuloplasty ring.4,5,7,11 Treatment ofAM is determined case by case. None of the present patientsequired additional surgery. For patient 1, a return to theperating room was unnecessary because her symptoms weremproving. For patient 2, SAM resolved with medical manage-ent in the operating room. Previous experience has suggested
hat medical management should be attempted first; if success-ul, a good long-term outcome can be anticipated.14
A decrease in MVA is expected after repair and has beenattributed to a decrease in the annular area after annuloplasty,use of an Alfieri suture technique, and/or plication of the mitralleaflet scallops.14-16 Although significant stenosis (MVA � 1.8and mean pressure gradient � 6 mmHg) is uncommon, it hasbeen reported and is more likely with more complicated re-pairs.14-16 One confounding issue is the lack of a readily avail-ble intraoperative gold standard to assess MVA. Only 2 stud-es have reported intraoperative MVA data and conflict on theccuracy of using pressure half time.17,18 Recent 3-dimensionalnalysis has shown that the postrepair mitral inflow area is notlanar, but rather more domed-shaped, helping to explain whyhe accuracy and feasibility of 2-dimensional and Dopplerchocardiographic analyses are decreased.17,19 Although thennular area is decreased because of the annuloplasty, a furtherecrease in MVA from this point to the leaflet tips has beenppreciated during qualitative assessment.19 The absence of an
Alfieri stitch or leaflet plication in patient 3 led the authors tobelieve that the moderate mitral stenosis was due to an excessmitral leaflet below the annular plane in a relatively smallerspace as seen during offline 3-dimensional analysis. The au-
itral valve repair. Changes in the mitral valve geometry are evident,
ter m
. AL, anterior leaflet; LA, left atrium; LV, left ventricle; PL, posterior
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97ISSUES AFTER POSTERIOR LEAFLET PRESERVATION
thors do not know of any prior reports describing this phenom-enon quantitatively. However, the data from patients undergo-ing RRR have shown that, despite the use of largerannuloplasty rings (32-34 v 30 mm), postrepair valvular hemo-dynamics and valve areas are not significantly different fromthe non-RRR groups.3,4,6,7 In fact, there was a trend toward alarger MVA in the non-RRR group (3.21 v 3.62 cm2; p � notignificant) at 1-year follow-up.6 Although a 32-mm ring waslaced in patient 3, it was adjusted to form a saddle shape,ikely contributing toward the narrowed inlet to the ventricle.
The proposed benefits of routine RRR have not been proved.n 2 reports of 2255 and 3977 patients, freedom from severe MRnd reoperation was statistically similar between those under-oing RRR and those undergoing PL resection. When theseutcome data are considered with the increased technical dif-
culty and longer CPB, aortic cross-clamp, and operating room
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ractice. J Am Soc Echocardiogr 22:1-23, 2009
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imes,6 it seems that preservation of the PL should be consid-ered a repair option and not a routine procedure.
The authors speculate that these immediate postrepair issueswere related directly to the increased or relative excess amount ofmitral leaflet below the annular plane. The cases highlight theinterdependence among the components of the mitral apparatusand their relation to surrounding tissues. Performance of PL repairand preservation, to preserve bileaflet function, requires additionalconsiderations to prevent postrepair complications. Echocardio-graphic evaluation before repair should provide the surgeon withinformation on the pathology and dimensions of the mitral appa-ratus, including leaflet lengths and systolic coapting heights. Al-though the accuracy of such measurements has not been studiedsystematically, it is the authors’ belief that such information wouldhelp the surgeon design the repair and improve short- and long-
term outcomes and function.
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