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J Thorac Cardiovasc Surg 2008;135:1287
© 2008 The American Association for Thoracic Surgery
Invited Commentary |
Dr. James I. Fann (Stanford, CA) Loris, I wish to congratulate you on a comprehensive presentation regarding the use of artificial chordae replacement in the repair of degenerative mitral valve disease. Included in your series is isolated anterior or bileaflet prolapse in nearly half the cases. What is impressive is the number of patients, the excellent early and late results, and the length and completeness of followup. It is believed that artificial chordae replacement in degenerative disease and posterior leaflet prolapse in particular may provide additional chordal support, maintain greater leaflet area, permit for more complex repair, and has the potential of decreased rate of failure.
My first question relates to the percentage of patients who had isolated posterior leaflet prolapse which comprised nearly 50% or 51% of patients who underwent chordal replacement in your group's experience. Here is the question. Do you think that a segmental leaflet resection and reconstruction with annuloplasty without chordal replacement - do you think that would have been sufficient in these patients or is chordal replacement absolutely necessary?
Dr. Salvador. Based on Cox regression analysis, we observed that quadrangular resection of the posterior leaflet is a protective factor only if associated with artificial chordae implant. Actually, I am not sure that the results would be the same without artificial chordae.
In the last years, we performed less frequently quadrangular resection and in this subgroup any redo was needed. In the first decade of this series, when resection was widely adopted, it provided excellent results, that made us pretty happy about performance at long-term follow-up. I don't know honestly how to explain why resection is a protective factor. I think that at the beginning of the experience, without intraoperative TEE we couldn't precisely analyze mitral valve pathology. So we performed more quadrangular resections of the posterior leaflet, the gold standard at that time, than we do at present. I think that, in future, we will evaluate the long-term results of this strategy, as more and more patients without resection will be included in a study.
Dr. Fann. From the surgical perspective, what technique do you employ to optimize the length or to adjust the chordae. That is, how do you size the length of the chordae? How do you size the ring for the mitral valve repair?
Dr. Salvador. Despite many suggestions that you can find in literature, we always use one simple method. We fill-up the ventricle with saline once the repair is completed. I mean after implanting the ring, quadrangular resection, if needed, or commissural fusion and whatever else you have to repair. At the very end, we fill the ventricle and we decide: to push or pull the leaflet, up or down, until we obtain a satisfactory coaptation. This is the only method we use. After acquiring an adequate experience we do not even pay so much attention to the length because it becomes something instinctual. I don't think is so fundamental to execute scientific measurements about distance between papillary muscles and annulus or something like this.
Dr. Fann. Do you oversize the annulus when you do the annuloplasty? I know you use the ...
Dr. Salvador. Most of our patients had autologous pericardium band implant and we adopt a very simple way to measure it, using the Carpentier sizers based on the patient's Body Surface Area. We assume that a BSA under 1.60 Square Meters, need the Carpentier's number 32 and we cut the band around that sizer. Between 1.60 and 1.80 we use a 34 sizer and above 1.80 the 36 sizer.
Dr. Fann. And finally you report that a total of 12 patients with more than 2+ MR were found immediately after surgery. What was the cause in these patients other than the those patients that you reported that had SAM that also had 2+ MR and how were these patients treated postoperatively?
Dr. Salvador. Actually, the patients were discharged! Mostly, this entity of post-operative MR was observed at the beginning of the experience, however in a small percentage of patients: 12 out of 608. First of all, I repeat, in the mid '80, it was difficult to have the echo in OR. At that time we had only normal transthoracic echo so we accepted this grade of insufficiency if it was found after leaving the OR. Right now it is a very rare event that a patient is discharged with such grade of insufficiency and there must be a very compelling reason. Today, it's very rare also to be discharged even with 1+. At the beginning of the experience we accepted it, considering that, in some patients, a second run of cardiopulmonary bypass would have been more risky than a 2+ mitral regurgitation.
Dr. Fann. Loris, thank you very much for an insightful presentation. I appreciate it.
Dr. Salvador. Thank you.
Related Article
J. Thorac. Cardiovasc. Surg. 2008 135: 1280-1287.
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