IJTCVS, Jan–Mar, 2006

Mitral valve repair for mitral regurgitation-When, where and how?- In the current eraKrishnan P, Pranav SK, Sivakumar K, Shahani J, Srinivas MApollo Hospital, Sri Lanka

Introduction: Valve repair is preferred over valve replacementfor mitral regurgitation (MR). Operative techniques have beenstandardized recently, based on the mechanism of MR. To determinethe results in the current era, we reviwed all the patients whounderwent mitral valve repair for MR, between June 2002 and July2005.

Methods: A total of 47 patients underwent valve repair for severeMR during a 3 year period. The etiology was myxomatousdegeneration in 27, rheumatic in 14, ischemic in 4 and infectiveendocarditis in 2. The predominant mechanism of MR was prolapse/flail anterior mitral leaflet (AML) in 11, of the posterior mitral leaflet(PML) in 20 and of both leaflets in 15. The remaining patients hadisolated annular dilatation. The techniques used for repair wereplication/resection of PML in 17, replacement or reinforcement ofchordae using expanded PTFE in 16, direct closure of leafletperforation in two and pericardial patch augmentation of the PML inone. All repairs were reinforced with a posterior annuloplasty usingprosthetic material and evaluated by intraop TEE. The remaining hadisolated posterior annuloplasty. Associated prodecures includedCABG in 10, aortic valve replacement in 6, ASD closure in 3.

Results: There were no early or late deaths on follow-up. All wereextubated within 24 hours after surgery. Four patients who hadplication/segmental resection of the PML developed systolic anteriormotion (SAM), as detected by intraop TEE SAM resolved in all casesith conservative therapy. There was no re-operation for recurrent MR.All except one patient had less than mild MR on follow-up echo. Allpatients were aticoagulated for 6 weeks. There were nothromboembolic or hemorrhagic complication.

Conclusions: Mitral valve repair techniques for severe MR due todegenerative heart disease are now standardized and can achieveexcellent predictable results in almost all patients. Replacement ofruptured chordae with ePTFE has eliminated the problem of SAMsometimes seen with the older technique of plication/resection of thePML and enabled successful repair of the flail AML. MV repair isespecially useful for improving survival in patients with severe MR& associated coronary artery or aortic valve disease & dilated,dysfunctional LV's

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Result of Chordal cutting as a treatment of MitralRegurgitation (MR) in patients of LV dysfunction(LVD)Jain A, Mallya S, Gupta V, Shah D, Nagesh A, Trivedi B,Shastri N, Mehta C, Jain K, Bhavsar N, Patel SThe Heart Care Clinic, Ahmedabad

Background: In patients of LVD. MR is seen because of tenting &tethering of anterior leaflet to displaced papillary muscle. Division ofanterior basal chordae can relieve tenting & thereby the MR in suchpatients.

Methods: We have tested the above hypothesis in 3 of our patientshaving moderate to severe MR and was suffering from IschemicCardiomyopathy & LV dilatation. All patients had 3+ MR, LV EDVof > 150 ml & LVESV of > 100 ml. 2 patients had globally dilated &hypokinetic ventricles & 1 patient had dyskinetic apical aneurysm.Intra operative transesophageal Echo showed significant MR withtenting of anterior mitral leaflet. 1 patient had septal exclusion withannuloplasty. One had overlapping cardiac volume reduction & onehad Tran’s aortic chordal cutting.

Results: Immediate & 6 month follow-up of these patients showedsignificant reduction in MR (trivial in one & mild in two). LV volumesalso regressed in all patients with improvement in NYHA status.

Conclusions: Chordal cutting works effectively in treatingIschemic MR but long term results will prove any deleterious effectof this procedure on function of mitral valve.

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The Ross operation: Our initial experienceRaj B, Shetty DP, Julius Punnen, Rathor R, John C, SharmaR, Thomas MNarayana Hrudayalaya, Bangalore

Background: The need for aortic valve replacement in children,young women and high risk male Patients poses a special problem tosurgeons. Replacing the diseased aortic valve with the patient’spulmonary valve as described by Sir Donald Ross has proven to be agood option. To review our initial experience in order to assess theshort-term results

Methods: From October 2001 to August 2005, 54 patients (age 3months to 65 years) underwent aortic valve replacement withpulmonary autograft. Indications for surgery were congenital aorticvalve disease in 42 patients, rheumatic fever in 6 and degenerative 6.Trans-esophageal echocardiography was performed preoperativelyand post-bypass in all patients, and transthoracic echocardiographywas done prior to discharge and on follow-up.

Results: There was no operative or late mortality. All patientsremain in functional class I (New York Heart Association) and arefree of complications and medication. None showed progression ofautograft insufficiency or LVOT obstruction in the limited period offollow up.

Conclusions: The Ross operation is an increasingly popularsurgical option in India, and although the number of patients andlength of follow-up are still limited, initial results are as good as thosereported internationally. It is important to continue a close follow-upof these patients to assess the long-term function of the autograft andhomograft. With the available data, we believe that this therapeuticapproach is a valid option for selected groups of patients with surgicalaortic valve disease in India.

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Valves 2006; 22: 56

Methods and Results: The “Valve Raquet” is a prosthetic ringtransformed into a requet by means of handmade mcsh usingexpanded polytetrafluoroethylene (ePTFE Gore-Tex). Aftertransection of the marginal chordae tendineae, five sheep the newracket implanted in the mitral (n=3) and in the tricuspid position (n=2).The surviving sheep underwent postoperative evaluation. After threemonths of operation a standard transthoracic study showed acompetent valves without significant gradients and without residualvalve regurgitation. Animals were killed with a single dose of sodiumthiopental. At gross inspection the ring appeared encapsulated by auniform fibrous tissue but the threads showed a completely denudedsurface except in the zone proximal to the ring. Examination with alight microscopy showed that thrombi or calcification deposits in thering, raquet’s mesh, or cardiac chamber were not abserved.

Conclusions: This initial experience confirmed the efficacy andsimplicity of the technique in the animal model.