Around the Mitral Valve With Nonresectional Repair Techniques

The authors present a series of degenerative mitral valve repair cases using nonresectional techniques that include posterior, anterior, bileaflet prolapse pathology, and Barlow’s disease. The leaflet flails and prolapses were readily repaired using neochordal Leipzig and Figure-of-8 locking adjustable stitch technique, while one of two Barlow’s cases was repaired with simple true-sized annuloplasty and the second one with the use of neochords plus the large annuloplasty. 

All cases were performed via a 1.5- to 2-inch right minithoracotomy incision. The fourth intercostal space was utilized in all cases, lateral to the pectorals major muscle. Liposomal bupivacaine was infiltrated immediately after skin incision for postoperative pain management (1). Femoral arterial and venous cannulation were used for cardiopulmonary bypass, and antegrade Del Nido cardioplegia was used for myocardial protection after applying a deployable crossclamp.

The Cryolife Chord-X (Kennesaw, GA) adjustable ePTFE suture system was used for repairing the valves. The technique relied on using a figure-of-eight locking stitch to adjust the individual ePTFE chords to correct the leaflet prolapse height (2). This Figure-of-8 adjustable locking stitch technique is a modification of the Leipzig loop technique pioneered by Dr Friedrich Mohr and his group (3). Instead of premeasured ePTFE, however, the authors used the adjustable technique, which they find to be a versatile method to address leaflet prolapse and flails of all segments of the mitral valve in a simple, effective, and reproducible fashion. This nonresectional repair technique allows for further adjustment of the repair if the leaflet in mention is too restricted or still prolapsed. Like the Leipzig loop technique, it also allows for a ‘true-sized’ (larger) annuloplasty ring implantation compared to the traditional resection techniques, which translates to lower transvalvular mean gradients (4). A full semirigid annuloplasty ring (Edwards Physio 2, Irvine, California) were implanted for all repairs. The exposure demonstrated in all cases consisted of a Miami instruments rib retractor with suture guide (not shown, Livanova, London, UK), the atrial lift retractor was the HV-Heart retractor (USB-Medical, Hartboro, Pennsylvania), and for papillary muscle exposure, the Superflex ‘ribbon’ retractor (Fehling, Karlstein, Germany) was used. 

Nonresectional techniques are an important component of the surgical technique “toolbox” of all cardiac surgeons. Most training programs will train residents in resectional techniques, including triangular and quadrangular techniques, but few do on neochordal reconstruction. In the authors’ opinion, nonresectional techniques such as the Leipzig loop and the modified version with the Figure-of-8 locking adjustable stitch represent reproducible and easy to learn techniques that should be considered when training cardiac surgery residents. 

References

1. Castillo-Sang M, Bartone C, Palmer C, Truong VT, Kelly B, Voeller RK, et al. Fifty percent reduction in narcotic use after minimally invasive cardiac surgery using liposomal bupivacaine. Innovations. 2019;4(6):512-518. 
2. El Gabry M et al, Minimally invasive video-assisted mitral valve repair using PTFE-chordae: a simplified technique. CTSNet. August 2018. doi:10.25373/ctsnet.6990317. 
3. Kuntze T, Borger MA, Falk V, Seeburger J, Girdauskas E, Doll N, et al. Early and mid-term results of mitral valve repair using premeasured Gore-Tex loops (‘loop technique’). Eur J Cardiothorac Surg. 2008. 33(4):566-572.
4. Falk V, Seeburger J, Czesla M, Borger MA, Willige J, Kuntze T, et al. How does the use of polytetrafluoroethylene neochordae for posterior mitral valve prolapse (loop technique) compare with leaflet resection? A prospective randomized trial. J Thorac Cardiovasc Surg. 2008;136(5):1200-1206.

Disclosure

Dr Castillo-Sang is a speaker for Edwards Lifesciences and Cryolife.

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