Mitral Valve Translocation: A Novel Technique for Patients with Secondary Mitral Regurgitation

Secondary mitral regurgitation (SMR) is the most common type of mitral regurgitation (MR), affecting up to 3.3 million individuals in the United States (1,2). The disease mechanism in secondary MR is largely ventricular—annular dilation, altered left ventricular geometry, leaflet tethering, insufficient leaflet coaptation—rather than valvular. The current standard of treatment, restrictive mitral annuloplasty (RMA), is associated with poor durability and nearly 60 percent recurrent MR within two years of operation, as depicted in the Cardiothoracic Surgical Trials Network randomized trial (3). This article’s author group has developed a novel operative repair for SMR: mitral valve translocation (MVT).

The Patient

This video presents the case of a fifty-eight-year-old patient who presented with chronic atrial fibrillation, congestive heart failure, and SMR despite being on maximum goal-directed medical therapy. In addition, the patient had moderate to severe tricuspid regurgitation on the preoperative imaging.

Based on experience, the surgical team offered the patient MVT, leaflet tethering and annular dilation seen in SMR are corrected by translocating the mitral valve leaflets apically with a circumferential, frustum-shaped patch.

This video demonstrates the technical aspects of performing MVT.

Step-by-Step Mitral Valve Translocation

1.  A median sternotomy was performed.

2. A large piece of the anterior pericardium was harvested and treated with 0.625 percent glutaraldehyde for three minutes, followed by three rinses in normal saline. A frustum-shaped circumferential pericardial patch was created on the back table, as described in the video.

3. The patient was fully heparinized and aortic and bicaval cannulation was performed.

4. Antegrade and retrograde cardioplegia cannulae were inserted.

5. The patient was placed on full cardiopulmonary bypass. An aortic cross-clamp was placed, and the heart was arrested with help of antegrade and retrograde cardioplegia.

6. Tricuspid ring annuloplasty was performed in standard fashion.

7. The mitral valve was exposed through the interatrial groove using a Cooley retractor.

8. A biatrial MAZE procedure was performed with cryothermy.

9. The native mitral valve was incised circumferentially with care taken to keep the commissures intact. The tertiary chordae were divided. The native mitral valve was displaced into the ventricle.

10. 3-0 braided nylon pledgeted sutures (TEVDEK) were placed circumferentially in the mitral valve annulus. Small hard pledgets were used to avoid purse-stringing and downsizing of the annulus.

11. 3-0 TEVDEKs were then brought through the sewing ring of the patch, which was mounted on a size 29 mitral valve sizer.

12. The patch was lowered into the annulus and the annular sutures were tied. A size 29 sizer was kept in the field while tying to prevent excessive downsizing of the annulus.

13. The team then proceeded to create the ventricular suture line—patch to the native mitral valve—by placing 5-0 Prolene stitches in the four quadrants and running them toward each on a quadrant-by-quadrant basis.

14. A saline test was performed and showed excellent coaptation.

15. The left atrium was closed using running 3-0 Prolene stitches.

16. The heart was de-aired and the aortic cross-clamp was removed.

17. The patient was slowly and methodically weaned from cardiopulmonary bypass.

18. An intraoperative TEE showed no residual mitral regurgitation and excellent leaflet coaptation.

19. Protamine was administered, and the heart was decannulated.

20. Finally, the sternum was closed.

References

1. Mozaffarian D., Benjamin EJ., Go ASet al. Heart disease and stroke statistics-2015 update: a report from the American Heart Association. Circulation 2015; 131: e29–e322. https://doi.org/10.1161/CIR.0000000000000152
2. de Marchena E., Badiye A., Robalino Get al. Respective prevalence of the different carpentier classes of mitral regurgitation: a stepping stone for future therapeutic research and development. J Card Surg 2011; 26: 385–392. https://doi.org/10.1111/j.1540-8191.2011.01274.
3. Michler RE., Smith PK., Parides MKet al. Two-year outcomes of surgical treatment of moderate ischemic mitral regurgitation. N Engl J Med 2016; 374: 1932–1941. https://doi.org/10.1056/NEJMoa1602003

Disclaimer

The information and views presented on CTSNet.org represent the views of the authors and contributors of the material and not of CTSNet. Please review our full disclaimer page here.