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J Thorac Cardiovasc Surg 2008;136:1102-1103
© 2008 The American Association for Thoracic Surgery

Letter to the Editor

Importance of stabilization of the mitral annulus in mitral valve repair

Department of Cardiac Surgery, Institution of Cardiology, University of Debrecen, Medical and Health Science Centre, Debrecen, Hungary

To the Editor:

We read with great interest the article of Flameng and coauthors¹ about their experiences with mitral valve repair in Barlow disease and fibroelastic deficiency. They found that not using annuloplasty ring in mitral valve repair is a risk factor for recurrent mitral valve regurgitation. We agree completely that the mitral annulus should be supported somehow, but our experience suggests that suture annuloplasty gives good results without any ring.

After our initial experience with suture annuloplasty, published 8 years ago,² we performed several hundred mitral repairs without annuloplasty rings and with good early and midterm results. There are two important factors in achieving a good result with this method. The first is the suture material. Both polypropylene (Prolene; Ethicon, Inc, Somerville, NJ) and polyester (Ethibond; Ethicon) sutures were not reliable. Prolene was too elastic, and in some cases the 3-0 Prolene thread elongated, causing redilatation of the mitral annulus. In a few cases, the Prolene suture ruptured, causing recurrent mitral regurgitation. Ethibond was difficult to use in achieving proper and equal tensions on the suture line and adequate shortening of the annulus. We had superior experiences with expanded polytetrafluoroethylene (Gore-Tex; W. L. Gore & Associates, Inc, Flagstaff, Ariz) sutures, as also reported by others.³ The other important factor is that the sutures be placed properly into the annulus. Neither sutures in the left atrium in the vicinity of the annulus nor sutures in the proximal parts of the valve cusps give good results. This should hold true even with ring annuloplasty.

Suture annuloplasty actually has advantages relative to ring annuloplasty. Transvalvular gradient is significantly lower and mitral valve area is significantly larger, without differences in mitral regurgitation.⁴ The mitral annulus has a natural flexibility, which results a 26% dilatation in diastole.⁵ The natural flexibility of the mitral annulus is conserved with suture annuloplasty. Suture annuloplasty is also a simpler and much cheaper method of achieving stability of the mitral annulus.

In our experience, if mitral repair is done, mitral annuloplasty should be performed, even if the annulus is not significantly dilated. It is not absolutely necessary to use an annuloplasty ring, as Flameng and coworkers recommend¹; suture annuloplasty can give a good result as well. Their statement that "[N]onuse of annuloplasty ring is a risk factor for recurrent mitral valve regurgitation" would be true only if the comparison included suture annuloplasty as well. We have not compared suture annuloplasty with annuloplasty rings, but in accordance with our experience, we would recommend the following conclusion instead: "Lack of stabilization of the mitral annulus increases the risk of recurrent mitral valve regurgitation."

References

1. Flameng W, Meuris B, Herijgers P, Herregods MC. Durability of mitral valve repair in Barlow disease versus fibroelastic deficiency. J Thorac Cardiovasc Surg 2008;135:274-282.[Abstract/Free Full Text]
   
2. Nagy ZL, Bodi A, Vaszily M, Szerafin T, Horvath A, Peterffy A. Five-year experience with a suture annuloplasty for mitral valve repair. Scand Cardiovasc J 2000;34:528-532.[Medline]
   
3. Duebner LF, Wendler O, Nikoloudakis N, Georg T, Fries R, Schäfers HJ. Mitral-valve repair without annuloplasty rings: result after repair of anterior leaflet versus posterior-leaflet defects using polytetrafluoroethylene sutures for chordal replacement. Eur J Cardiothorac Surg 2000;17:206-212.[Abstract/Free Full Text]
   
4. Detter C, Aybek T, Kupilik N, Fischlein T, Moritz A. Mitral valve annuloplasty: comparison of the mural annulus shortening suture (MASS) with the Carpentier-Edwards prosthetic ring. J Heart Valve Dis 2000;9:478-486.[Medline]
   
5. Ormiston A, Shah PM, Tei C, Wong M. Size and motion of the mitral valve annulus in man. A two-dimensional echocardiographic method and findings in normal subjects. Circulation 1981;64:113-120.[Abstract/Free Full Text]
   

This Article Full Text (PDF) 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 Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): István Szentkirályi Árpád Péterffy Zoltán Galajda Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Szentkirályi, I. Articles by Galajda, Z. Search for Related Content PubMed Articles by Szentkirályi, I. Articles by Galajda, Z. Related Collections Cardiac - physiology Valve disease