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J Thorac Cardiovasc Surg 1999;118:1154-1155
© 1999 Mosby, Inc.

LETTERS TO THE EDITOR

Cinefluoroscopic assessment of human mitral anulus after mitral valvuloplasty

Divisione di Chirurgia Cardiovascolare, Ospedale "L. Sacco", Via G. B. Grassi n.74
20157 Milan, Italy

To the Editor:

I read with great interest the article "Mitral Annular Size and Shape in Sheep With Annuloplasty Rings" by Glasson and associates. ¹ I am very much impressed with their complete analysis. The mitral anulus is a complex structure. Complexity derives from its composition, its geometric relationships, and its pathophysiology. The literature contains ample evidence about the maintained movements of the mitral anulus even after annuloplasty.

Okada and associates ² have shown that the motion of the mitral anulus during the cardiac cycle after mitral valve repair for chronic mitral regurgitation due to degenerative disease is affected by the type of annular device used. Of most importance, however, is that the diastolic blood flow across the mitral orifice during exercise was better in patients in whom a flexible ring was used. Mitral annuloplasty has always been a target for the cardiac surgeon. Pathophysiologic findings prompted many authors to develop flexible rings to avoid rigid fixation of the mitral anulus.

I would like to report the experience of my colleagues and me, ³ which is similar to that of the authors (as a method but not as a conclusion). In 1991 we experimented with a new technique using autologous pericardium to obtain a flexible ring that could preserve the physiologic mitral annular motion after valvuloplasty. In a subgroup of patients (n = 20) who underwent mitral valvuloplasty because of degenerative disease, a long strip of pericardium was prepared, marked with a metal clip, and rolled up in a tubular fashion with the serosal surface on the outside. The pericardial tube was apposed on the posterior anulus just beyond the commissures. Postoperative Doppler echocardiographic analysis showed nearly normal transmitral flow indexes (flow velocity peak: 1.06 ± 0.2; P = no significant difference from normal indexes). Cinefluoroscopic examination was used for assessing annular motion with the metal clips used as radiopaque markers. Planimetry of the hemi-area showed a narrowing of annular size during ventricular systole (mean 8.5% ± 6.4%). Even long-term results seems to be good. ⁴ These findings, as corroborated by others authors, demonstrate that the flexible properties of the mitral orifice are preserved equally well after this type of annuloplasty in man.

The aim of this letter is not to criticize. However, I would suggest that the authors’ "surprising results" must be considered with extreme caution and additional studies should be required to establish the overall effectiveness of their method both in the animal model and in human beings.

References

1. Glasson JR, Green GR, Nistal JF, Dagum P, Komeda M, Daughters GT, et al. Mitral annular size and shape in sheep with annuloplasty rings. J Thorac Cardiovasc Surg 1999;117:302-9. [Abstract/Free Full Text]
   
2. Okada Y, Shomura T, Yamura 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]
   
3. Salati M, Scrofani R, Santoli C. Posterior pericardial annuloplasty: A physiologic correction? Eur J Cardiothorac Surg 1991;5:226-9. [Abstract]
   
4. Scrofani R, Moriggia S, Salati M, Fundaró P, Danna P, Santoli C. Mitral valve remodeling: long-term results with posterior pericardial annuloplasty. Ann Thorac Surg 1996;61:895-9. [Abstract/Free Full Text]
   

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