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J Thorac Cardiovasc Surg 1995;110:859-0861
© 1995 Mosby, Inc.

BRIEF COMMUNICATIONS

Transfer of the posterior tricuspid leaflet and chordae for mitral valve repair

Ulrik Hvass, MDa, José Calliani, MDa, Isabelle Nataf, a, Jean Michel Julliard, MDb, Alex Vahanian, MDc

Paris, France

Efficient mitral valve repair is preferable to mitral valve replacement. The issue is particularly important in young female patients to avoid anticoagulants or rapid deterioration of xenografts.

The variety of techniques proposed for mitral valve repair is already impressive and responds to anatomic and functional necessities. Among others, the techniques comprise the "French correction,"Go 1 creation of several anuli,transfer of segments of the posterior leaflet,Go 2 use of artificial chordae,Go 3 valvular augmentation with thepatient's own tanned pericardium,Go 4 and use of segments of mitral cryopreserved homografts with their chordae.Go 5

We report on a new technique that allowed us a conservative approach in a difficult case.

A 22-year-old Algerian woman had isolated rheumatic mitral stenosis. Preoperative echographic evaluation showed a calculated surface area of 0.7 cm2, a mean transvalvular gradient of 16 mm Hg, a trivial central leak, a mobile anterior leaflet, a retracted posterior leaflet, and a fused, thickened subvalvular apparatus.

Although not an ideal candidate, the patient was finally accepted for percutaneous mitral dilatation by Professor Vahanian of the Tenon Hospital in Paris, who has extensive experience in the field. The procedure resulted in a tear of the posterior leaflet, with severed chordae and grade III mitral regurgitation. Catheterization of the right side of the heart showed a capillary pressure of 26 mm Hg and a pulmonary artery pressure of 45/25 mm Hg (mean 30 mm Hg). The patient was scheduled for surgery 3 days later.

At operation, the mitral anulus was rather small, and the anterior leaflet was flexible. The anterior commissure had a 3 mm tear, which had been stopped by fused and short (5 mm) submitral anterior chordae. A long irregular tear was located near the posterior commissure, extending to the anulus of the posterior leaflet. Several chordae had been severed.

We proceeded as follows: The anterior commissure was opened a further 4 to 5 mm and a 2 cm split was created in the anterior papillary muscle. Direct suture of the lacerated posterior leaflet gave an unsatisfactory result, with insufficient opening and unacceptable regurgitation. The possibility of any form of repair seemed compromised, and only a small xenograft, probably 25 mm, would have been suitable for the patient's anulus and small left ventricle. We decided to evaluate the tricuspid valve. The anulus was large and the valvular tissue normal. The posterior leaflet, its chordae, and its muscular attachment were well individualized. This portion of the tricuspid valve was removed and transferred to the mitral commissure (Fig. 1). The tricuspid papillary muscle was reattached to the corresponding mitral papillary muscle with several pledget-supported sutures. The leaflet was reattached to the mitral anulus and adjacent mitral tissue with interrupted 5-0 monofilament sutures. Injection of saline solution into the left ventricle, to test for mitral competence, showed a good result. We did not use a prosthetic mitral anulus. The tricuspid valve was repaired by annular plication and leaflet suture.



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  		Fig. 1. Transfer of posterior tricuspid leaflet to the mitral valve. AML, Anterior mitral leaflet; ATL,anterior tricuspid leaflet; PML, posterior mitral leaflet; PTL, posterior tricuspid leaflet; STL, septal tricuspid leaflet.

 
The postoperative course was uneventful. A transesophageal echocardiogram 2 weeks later showed narrow mitral regurgitation located at the level of the anterior commissure and extending along the anterior leaflet (Fig. 2), with normal function in the area of the reconstructed posterior commissure, a mean transmitral gradient of 8 mm Hg, and a calculated surface area of 1.95 cm2. The tricuspid valve had a mild to moderate leak.



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  		Fig. 2. Postoperative transesophageal echocardiogram shows narrow regurgitation that follows the anterior mitral leaflet.

 
Although many questions remain unanswered with this type of repair, use of the posterior leaflet of the tricuspid valve may be helpful for mitral repair.

Footnotes

From Cardiovascular Surgerya and the Department of Cardiology,b Hôpital Bichat, and the Department of Cardiology,c Hôpital Tenon, Paris, France. Back

J THORAC CARDIOVASC SURG 1995;110:859-61 Back

References

  1. Carpentier A. Cardiac valve surgery—the "French correction." J THORAC CARDIOVASC SURG 1983;86:323-37.[Medline]
  2. Hvass U, Pansard Y, Lamberti A, et al. Réparations de lésions mitrales rhumatismales par transfert d'un segment de la valve posterieure avec ses cordages sur la valve anterieure. Arch Mal Coeur 1986;1:103-6.
  3. David TE, Boss J, Rakowski H. Mitral valve repair by replacement of chordae tendinae with polytertrafluoroethylene sutures. J THORAC CARDIOVASC SURG 1991;101:495-501.[Abstract]
  4. Pellerin M, Chauvaud S, Chachques JC, Carpentier A. Mitral leaflet extension with glutaraldehyde treated autologous pericardium. Presented at the Sixth International Symposium on Cardiac Bioprostheses. Vancouver, BC, Canada. July 29-31, 1994.
  5. Acar C, Farge A, Ramsheyi A, et al. Mitral valve replacement using a cryopreserved mitral homograft. Ann Thorac Surg 1994;57:746-8.[Abstract/Free Full Text]



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F. Gregori Jr, C. O. Cordeiro, U. A. Croti, S. S. Hayashi, S. S. da Silva, and T. E.F. Gregori
Partial tricuspid valve transfer for repair of mitral insufficiency due to ruptured chordae tendineae
Ann. Thorac. Surg., November 1, 1999; 68(5): 1686 - 1690.
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