Mitral Valve Annuloplasty Surgical Repair

Mitral valve disease is variable from patient to patient and can be seen due to isolated mitral valve defects or in conjunction with other complex left sided lesions like hypoplastic left heart syndrome or Shone’s complex [1]. Mitral valve surgery alleviates symptoms of heart failure, prevents or reverses ventricular modeling and decreases overall mortality in patients diagnosed with mitral valve diseases [2]. Historically, Mitral valve replacement has had high mortality rates and an increased rate of complications, especially in children, so alternatives like mitral valve repairs have emerged as safer options [3, 4]. Mitral valve annuloplasty is currently considered the gold standard for management of mitral valve regurgitation [5]. Our video highlights successful Mitral Valve Annuloplasty in a patient with mitral valve regurgitation, prolapse and a dilated left atrium and ventricle.

This is a case presentation of a 17-year-old female that presented to clinic with a 3/6 systolic ejection murmur. Echocardiography showed mitral annulus dimension of 3.65 cm, anterior mitral leaflet prolapse into the left atrium, regurgitant jet courses along the posterior wall of the left atrium suggesting mitral valve insufficiency and both a moderately dilated left atrium and ventricle. Dedicated cardiac MRI imaging showed mitral valve regurgitation, a Left Ventricular Ejection Fraction of 52% and a Mitral Valve diameter of 41 mm.  Due to the low ejection fraction, left ventricular dilation and the mitral valve regurgitation, surgical repair was deemed appropriate.

The patient was heparinized and after median sternotomy and bi-caval cannulation cardiopulmonary bypass commenced. Upon the opening of the right atrium, a longitudinal incision was made into the fossa ovalis for trans-atrial exposure of the mitral valve. In order to visualize the degree of regurgitation, saline was used to test the mitral valve.  Attention is then drawn to the both the posterior and anterior mitral valve leaflets. The mitral valve prolapse is identified as a section of the A2/A3 region of the anterior leaflet and is inspected to indicate the degree of exposure and the elongated chordae tendineae. The mitral valve showed mitral valve regurgitation throughout the valve. A Physio Ring Sizer mitral valve sizer was used to measure the distance between the mitral valve trigones and a 28 mm annuloplasty ring was selected. A 28 mm Carpentier-Edwards Physio II annuloplasty ring was used downsize the mitral valve annulus. 2-0 Ethibond non-plegeted Horizonal mattress sutures were placed through the annular tissue to the annuloplasty ring. It should be noted that to accomplish a sufficient downsizing of the annulus, longer distance was traveled on the native tissue annulus compared to the length between suturing on the prosthetic ring.  This allows for mitral valve leaflet coaptation via an annuloplasty repair of the mitral valve. The annuloplasty ring was then secured using CorKnots After seating the Physio-ring, saline was injected to evaluate the repair. An additional leak was noted from the cleft between A2/A3 segments. This cleft was repair with a plegeted 5-0 Prolene. Serial saline injections demonstrated no further regurgitation. The patient was then successfully weaned off cardiopulmonary bypass after adequate hemostasis was closed in the standard fashion.

Post-Op TEE demonstrated normal cardiac function, mild mitral valve regurgitation. While in normal sinus rhythm a 5-6 mmHg gradient was observed. Left ventricle is still mildly dilated and patient shows no evidence of Left Ventricular Outflow or Right Ventricular Outflow Obstruction. Chest Tubes and Epicardial pacing wires were removed post-operative day 1, and patient was discharged on post-operative day 5

This video highlights a successful placement of a mitral valve annuloplasty ring to alleviate mitral valve regurgitation and prolapse. Repair of the mitral valve and mitral valve annulus should prevent or reverse ventricular modeling and decrease the overall mortality in patients diagnosed with mitral valve diseases [2]. Surgical approach should always be to repair of the native valve, rather than replace. Native valve repair in children is advocated for due to consistent anticoagulative therapy that accompanies mitral valve replacement. Due to the patient’s younger age, it is possible that re-operation will be necessary as she continues to grow older. Continual cardiology follow-up and imaging is advised for successful cardiac outcome.

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1. Baird, C., et al., Mitral valve operations at a high-volume pediatric heart center: Evolving techniques and improved survival with mitral valve repair versus replacement. Annals of Pediatric Cardiology, 2012. 5(1): p. 13. 2. Gammie, J.S., et al., Isolated Mitral Valve Surgery: The Society of Thoracic Surgeons Adult Cardiac Surgery Database Analysis. The Annals of Thoracic Surgery, 2018. 106(3): p. 716-727. 3. Vassileva, C.M., et al., Meta-analysis of short-term and long-term survival following repair versus replacement for ischemic mitral regurgitation. European Journal of Cardio-Thoracic Surgery, 2011. 39(3): p. 295-303. 4. Alsoufi, B., et al., Results after mitral valve replacement with mechanical prostheses in young children. The Journal of Thoracic and Cardiovascular Surgery, 2010. 139(5): p. 1189-1196.e2. 5. Ferrao De Oliveira, J.M., Mitral valve repair: better than replacement. Heart, 2006. 92(2): p. 275-281.