Mitral valvuloplasty with a new prosthetic ring. Analysis of the first 105 cases

Premolded bovine pericardial chords for replacement of ruptured or elongated chordae tendineae

BACKGROUND

The aim of this study was to assess by Doppler echocardiography (ECO) the functioning of the mitral valve apparatus in patients who have undergone implantation of standardized bovine pericardium chordae (SBPC) for replacement of ruptured or elongated chordae tendineae with significant thinning.

METHODS

SBPC were implanted in 31 patients who had mitral insufficiency due to rupture of chordae tendinae or elongated chordae with significant thinning. Patient ages ranged from 19 to 85 years (mean of 58 years). The most frequent cause of mitral insufficiency was fibroelastic degeneration in 25 patients (80.6%). The SBPC were fashioned as a set, joined at their extremities by 2 polyester-reinforced rods forming a monobloc. The SBPC were 2-mm wide and were positioned parallel to one another at a distance of 3 mm. Each set of SBPC had a corresponding measurer, and their length ranged from 20 to 35 mm. In 21 patients (67.7%) the SBPC were implanted in the posterior leaflet and in 10 patients (32.3%) in the anterior leaflet (in 2 patients concurrently in the anterior and posterior leaflets). All patients were assessed by ECO postoperatively, with a 20-month mean follow-up time (range 6-45 months).

RESULTS

One patient (3.2%) died of pulmonary embolism during the early postoperative period. Postoperative ECO showed absence of mitral regurgitation in 17 patients (54.8%), mild regurgitation in 9 (29.0%), and mild-to-moderate regurgitation in 4 (12.9%). Opening and mobility of the mitral valve were normal in the 30 surviving patients.

CONCLUSION

The ECO revealed good functionality of the mitral valve apparatus with appropriate leaflet coaptation in patients who had undergone implantation of SBPC for replacement of ruptured or elongated and thinned chordae. A longer follow-up is required to assess absence of calcification and/or degeneration of the SBPC.

Partial tricuspid valve transfer for repair of mitral insufficiency due to ruptured chordae tendineae

BACKGROUND

A new technique is suggested for the reconstructive surgical treatment of mitral regurgitation. It involves partial transfer of the tricuspid valve of the patient to the mitral valve, in order to provide chordae to correct anterior leaflet prolapse of the mitral valve, secondary to rupture of the chordae tendineae.

METHODS

From January 1991 to May 1997, 20 patients with mitral insufficiency due to rupture of the chordae were operated on. The prevailing cause was myxomatous degeneration (70%). Patients were in New York Heart Association functional class III and IV.

RESULTS

There were no hospital deaths. Two patients were reoperated on. Eighteen patients (90%) are alive with their own valves (class I and II). Doppler echocardiogram mean values were: ejection fraction, 0.65; left atrial diameter, 4.2 cm; mitral area, 2.4 cm2; mitral transvalvular gradient, 3.3 mm Hg. No regurgitation or mild regurgitation was observed in 16 (94.1%) of the 17 cases evaluated. Mean tricuspid valvular area was 3.3 cm2. In all cases, no tricuspid regurgitation was present or it was mild.

CONCLUSIONS

Partial transfer of the tricuspid valve to the mitral valve is an effective procedure for the surgical treatment of mitral valve insufficiency secondary to ruptured chordae tendineae of the anterior leaflet.

Cox maze operation without cryoablation for the treatment of chronic atrial fibrillation

BACKGROUND

From August 1993 to May 1994, 20 patients (mean age, 43 years) with atrial fibrillation underwent the maze operation without cryoablation. Ten patients had mitral stenosis, 5 had mitral insufficiency, and 5 had a mixed mitral lesion. The mean left atrial diameter as measured on echocardiograms was 6.1 cm. The cause was rheumatic in 17 patients (85%) and degenerative in 3 (15%). Seven patients had had previous episodes of thromboembolism.

METHODS

Mitral valvuloplasty was performed on 7 patients, mitral commissurotomy on 4, and mitral valve replacement on 9. Thrombi were found in the left atrium of 7 patients and also in the right atrium in 2. The mean cross-clamp time was 73 minutes (range, 52 to 108 minutes).

RESULTS

Patients were discharged from the hospital in good condition. Hemodynamic studies and Doppler echocardiograms showed significant reduction in the left atrial diameter (mean diameter, 4.9 cm; p < 0.01) in 18 patients. The two-channel Holter monitor showed sinus rhythm in 15 patients, atrial ectopic rhythm in 4, and atrial fibrillation in 1. Eleven patients (55%) experienced atrial fibrillation (9 in the first 3 months postoperatively), which was reversed with quinidine. Ninety percent of patients had development of an effective, synchronous, atrial systole. Six to 15 months postoperatively (average follow-up, 10 months), all patients were in functional class I, and 18 were not on a regimen of antiarrhythmic medication.

CONCLUSIONS

This simplification of the maze operation has been demonstrated to be an effective alternative for the treatment of chronic atrial fibrillation.