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J Thorac Cardiovasc Surg 1996;112:196-197
© 1996 Mosby, Inc.

BRIEF COMMUNICATIONS

A NONNARROWING TECHNIQUE FOR IMPLANTATION OF THE DURAN FLEXIBLE RING

Jose M. Bernal, MD, Jose M. Revuelta, MD


Santander, Spain

From the Department of Cardiovascular Surgery, Hospital Universitario Valdecilla, Universidad de Cantabria, Santander, Spain.

Received for publication Sept. 5, 1995 Accepted for publication Sept. 19, 1995. Prosthetic ring annuloplasty is a common procedure in both mitral and tricuspid valve repairs. The question of the optimum form of annuloplasty ring, however, whether rigid, semirigid, or entirely flexible, is still controversial. Although in a recent clinical study Okada and associatesGo 1 showed that flexible rings perform better under exercise conditions, the narrowing effect of the Duran flexible ring has been considered a disadvantage in comparison with remodeling annuloplasty with the rigid Carpentier ring.Go 2 This report describes a nonnarrowing technique for Duran flexible ring annuloplasty.

Technique

At operation, the left atrium is entered just posterior to the interatrial groove and anterior to the pulmonary veins. The mitral valve is examined, and traction in the middle portion of the free edge of the anterior leaflet allows visualization of the trigones. An appropriately sized ring is selected according to the intertrigonal distance. Two 3-0 polypropylene double-armed sutures are placed in both trigones, and an additional suture is placed in the middle part of the posterior anulus. Stitches in the trigones are placed through the two ring markers (Fig. 1, Step 1). A running 3-0 polypropylene suture is used to seat the flexible ring along the intertrigonal area. The stay suture in the middle part of the posterior anulus is used as a key reference for reduction of the dilated mitral anulus. The suture placed in the anterior trigone is then run clockwise to join the stay suture (Fig. 1, Step 2), and the suture in the posterior trigone is run counterclockwise to be tied with the other stitch (Fig. 1, Step 3). The atriotomy is closed and air is vented from the heart. The patient is weaned from bypass, and proper functional results are assessed by transesophageal echocardiography before the cannulas are removed.



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  		Fig. 1. Mitral valve annuloplasty with Duran flexible ring secured by a running suture. T, Trigone.

 
Discussion

Annuloplasty with flexible rings is a safe and stable reconstructive procedure (89.9% ± 3.2% free from mitral structural deterioration at 16 yearsGo 3) in which preservation of spatial motility and configuration of the anulus allows a more physiologically natural valve repair with improvement of ventricular function. The results obtained with rigid versus flexible anuloplasty rings inserted using interrupted sutures are different. The rigidity of the Carpentier ring prevents deformity, whereas when the Duran flexible ring is sutured to the anulus by interrupted U-stitches multiple plications of the Dacron polyester fabric occur (Fig. 2). This process causes narrowing of the prosthetic ring and is a potential cause of valve stenosis. Although a decreased valve area usually has no clinical significance, plication of the annuloplasty ring determines a reduction of at least one or two sizes in the selected device. The residual stenotic effect without early hemodynamic repercussion, together with progression of the underlying disease, may be a predisposing factor toward valve stenosis necessitating late reoperation. The incidence of thromboembolic episodes detected in our series, which is slightly higher than that reported by others using the Carpentier ring,Go 3 could be attributed in part to the distortion of the Dacron ring.



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  		Fig. 2. Different results produced by interrupted U-sutures in Carpentier (no deformity) and Duran (plication) ring annuloplasties. Duran flexible ring with a running suture is also shown (no deformity).

 
The rationale for the technique described here was based on different factors. On the one hand, some patients in whom Duran flexible rings had been inserted required valve-related operations as a result of hemolysis with or without prosthetic dehiscence; on the other, patients who underwent reoperation for mitral restenosis showed absence of endothelium in the areas in which the ring was folded. Analysis of our experience with rheumatic mitral valve disease reveals that as many as 14.7% of the patients evaluated echocardiographically showed a valve area of less than 1.5 cm2.Go 3 In recipients of cryopreserved mitral homografts, the annular suture line has been reinforced with a Duran flexible ring inserted by means of a continuous over-and-over suture, with annuloplasty used to support the repaired valveGo 4 rather than to achieve a reduction in size of the native anulus. This modification resulted in remodeling of the anulus without stenosing folds or plications (Fig. 2). Other authors have also used running sutures to insert annuloplasty rings, such as the adjustable Puig-Massana ring or a flexible ring constructed from transverse sections of knitted Dacron polyester fabric.Go 5 In case of failure of mitral valve repair, explantation of the annuloplasty ring is simplified to cutting a single suture.

Footnotes

J THORAC CARDIOVASC SURG 1996;112:196-7 Back

References

  1. Okada Y, Shomura T, Yamaura Y, Yoshikawa J. Comparison of the Carpentier and Duran prosthetic rings used in mitral reconstruction. Ann Thorac Surg 1995;59:658-63.[Abstract/Free Full Text]
  2. Carpentier A. Mitral valve annuloplasty [Letter]. Ann Thorac Surg 1990;49:508.[Medline]
  3. Bernal JM, Rabasa JM, Vilchez FG, Cagigas JC, Revuelta JM. Mitral valve repair in rheumatic disease. the flexible solution. Circulation 1993;88:1746-53.[Abstract/Free Full Text]
  4. Revuelta JM, Bernal JM, Rabasa JM. Partial homograft replacement of mitral valve. Lancet 1994;344:514.[Medline]
  5. Cooley DA, Baldwin RT, Wilansky S. A cost-effective Dacron annuloplasty ring. Ann Thorac Surg 1993;56:185-6.[Abstract]




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