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J Thorac Cardiovasc Surg 1998;115:727-729
© 1998 Mosby, Inc.

BRIEF COMMUNICATIONS

Mitral regurgitation late after manouguian's anulus enlargement andaortic valve replacement

Tokyo, Japan

From the Department of Cardiothoracic Surgery, University ofTokyo,^a and JR Tokyo General Hospital,^b Tokyo, Japan.

Received for publication Nov. 4, 1997. Accepted for publication Nov. 13, 1997. Address for reprints: Joseph B. Zwischenberger, MD, Division ofCardiothoracic Surgery, 301 University Blvd., University of Texas MedicalBranch, Galveston, TX 77555-0528.

Anulus enlargement is necessary in some patients with small aortic anuli.The Manouguian procedure ¹usually makes it possible to accommodate a prosthetic valve two sizes largerthan the original anulus and is applicable in various situations. ^2-5Although it is a well-established method, its long-term results have not beenwell documented. Concern has been expressed about the long-term effects of thisprocedure on mitral valve function, because the structure of the anterior mitralleaflet and the mitral anulus are inevitably altered. Herein we report thatsignificant mitral regurgitation (MR) often occurred late after the Manouguianprocedure performed with a prosthetic patch.

Clinical summary

Four patients (one man and three women) underwent aortic valvereplacement by means of the Manouguian procedure with prosthetic patches becauseof congenital aortic stenosis and a small anulus between 1981 and 1989. Anexpanded polytetrafluoroethylene (ePTFE) patch was applied in three patients,and a woven Dacron patch was used in one. Mean age at operation was 25 years.The mean follow-up period was 134.5 months. The size of the prosthetic valve was21 mm in two patients, 19 mm in one, and 17 mm in one. Mitral prolapse and MRdeveloped late after the operation in all four patients. In three of fourpatients who had been followed up longer than 10 years, mitral prolapse wasmarked and the grade of MR was greater than moderate. One patient whosefollow-up period was 7 years had mild prolapse and mild MR. The anterior leafletprolapsed and regurgitant flow was oriented toward the posterior wall of theleft atrium. Mobility of the basal portion of the anterior mitral leaflet waspoor. This portion was highly echogenic and thought to be prosthetic material.On the other hand, the marginal portion of the anterior leaflet was fully mobilebut prolapsed. The echogenicity of this portion was normal or only slightlyenhanced. Inasmuch as mobility differed markedly between the native mitral valveand the prosthetic patch, the anterior leaflet appeared to have a joint with abend at the junction (Fig. 1). However, the abnormal motion, prolapse,and MR were absent in the early postoperative period. Serial echocardiographicstudies in two patients with an ePTFE patch revealed that the mitral valve hadinitially appeared almost normal. Abnormal findings in the mitral valve and MRbecame apparent about 5 years later and then deterioration increased (Fig. 2). Such an abnormal motion or significantMR were not observed in four patients in whom autologous pericardium had beenused as a patch, although mild mitral prolapse was commonly seen in thesepatients as well.

View larger version (84K): [in this window] [in a new window]   Fig. 1. Typical motion ofmitral valve late after the Manouguian procedure with a prosthetic patch.Left, Systolic phase. Right,Diastolic phase. Because of the difference of mobility and stiffness between theprosthetic patch (arrow) and the native valve,the anterior leaflet appears to be bent.

View larger version (77K): [in this window] [in a new window]   Fig. 2. Deterioration ofabnormalities in the anterior mitral leaflet. Left,One year after the operation. There was no MR. Middle,Six years later. Mild MR was observed. Right,Twelve years later. Moderate degree of MR was present. Arrow, Prosthetic patch.

We found that significant MR resulting from mitral prolapse was common inpatients who had undergone the Manouguian procedure with a prosthetic patch. Itis clear that poorly flexible, firm material is unsuitable for the patch,because it forms a part of the mitral valve. However, significant MR alsooccurred in patients in whom ePTFE, an originally soft material, was used. Thefact that the abnormalities in the mitral valve developed at a latepostoperative stage and were progressive strongly suggests that the cause of MRin these patients was patch degeneration rather than an inappropriate incision. ² We actually encountered strikinglysevere degeneration of ePTFE at a reoperation 7 years after the Manouguianprocedure. The patch was too stiff to function as part of the heart valve,although prolapse and MR were mild in this case. Therefore it appears better notto use synthetic prosthetic patches that may degenerate later on. In thisregard, bioprosthetic material may also not be a good choice for the patch. Evenallografts are not free from degeneration. In our experience, patients with anautologous pericardial patch had better results. Abnormal motion of the mitralvalve or significant MR was not present in any of them. However, shrinkage andsclerosing change of the autologous pericardium are also well known. At present,the ideal patch material for the Manouguian procedure does not seem to exist. Inaddition, acceptable morphologic alteration of the mitral anulus and theanterior leaflet in this procedure is yet unclear, especially in pediatricpatients. Therefore every patient undergoing the Manouguian procedure needscareful follow-up.

References

1. Manouguian S, Seybold-Epting W. Patchenlargement of the aortic valve ring by extending the aortic incision into theanterior mitral leaflet. J Thorac Cardiovasc Surg 1979;78:402-12.[Abstract]
   
2. Kawachi Y, Tominaga R, Tokunaga K.Eleven-year follow-up study of aortic or aortic-mitral anulus-enlargingprocedure by Manouguian's technique. J Thorac Cardiovasc Surg 1992;104:1259-63.[Abstract]
   
3. Okabe H, Asano K, Mizuno A, et al. Clinicaland anatomical evaluation of Manouguian's procedure. J Jpn Assoc Thorac Surg 1986;34:1884-91.
   
4. Manouguian S, Abu-Aishah N, Neitzel J. Patchenlargement of the aortic and mitral valve rings with aortic and mitral doublevalve replacement. J Thorac Cardiovasc Surg 1979;78:394-401.[Abstract]
   
5. Furuse A, Mizuno A, Asano K. Aortoatrioplastywith double valve replacement for infective endocarditis. J Cardiovasc Surg 1984;25:462-6.
   

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This Article Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Shinichi Takamoto Akira Furuse Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Imanaka, K. Articles by Furuse, A. Search for Related Content PubMed PubMed Citation Articles by Imanaka, K. Articles by Furuse, A.