Fig. 11.1
Annuloplasty suture starts at the right fibrous trigone and a single bite (step) involves 7–9 mm of mitral valve annulus, and pledgets are positioned at the commissures, posterior leaflet identations and in the midportion of P2
Fig. 11.5
Line diagram showing the placement of pledgets and sutures for suture annuloplasty. Note that the first and last pledgets are placed at the fibrous trigones and are oriented parallel to the mitral annulus, all other pledgets in between are orientated perpendicular to the mitral annulus and are positioned at the commissures, at the clefts between P1 and P2, between P2 and P3 and in the middle of the P2 scallop. Abbreviations: ALC anterolateral commissure, PMC posteromedial commissure, A1–A2–A3 anterior mitral valve leaflet scallops, P1–P2–P3 posterior mitral valve leaflet scallops
All the pledgets are placed perpendicular to the mitral valve annulus except at the two trigones in order to avoid suture “waves” that can lead to suture straightening and loosening with subsequent annulus dilatation under volume loaded LV conditions. After the suture reaches the left fibrous trigone, the last pledget is oriented parallel to the annulus, and the suture tied. The posterior annulus is adjusted to the mitral valve anterior leaflet surface area size. This maneuver can be performed also using commercially available heart valve sizers (Fig. 11.3). By pulling the double Ethibond suture, one plicates the posterior annulus, and the perpendicular position of the pledgets allows this maneuver to be performed without excess tension on the mitral valve annulus at the suture insertion site. Also, the pledgets will disappear within the wrinkles of the atrial endocardium without distorting or deforming the mitral valve posterior annulus and leaving minimum amount of prosthetic material within the left atrium (Fig. 11.4). Also, it should be noted that the preferred positions of the pledgets are: both commissures, the clefts between P1-P2 and P2-P3 and the central part of the P2 scallop (Fig. 11.5). The positioning of the pledgets, regardless of the degree of posterior annulus diameter reduction, does not affect the shape and surface of posterior mitral valve leaflet (Fig. 11.6).
Fig. 11.3
Sizing of the MV annulus with heart valve sizer
Fig. 11.4
Mitral valve view after suture annuloplasty is completed. Note: the shape of the mitral valve annulus is round and the pledgets disappear with endocardial folds
Fig. 11.2
Line diagram showing the direction of needle placement avoiding the coronary vessels in the atrioventricular groove. Abbreviations: atrium-left atrial wall, ventricle-left ventricular wall base, PML posterior mitral valve leaflet, CS coronary sinus, CA coronary artery
Fig. 11.6
3D echocardiographic image of suture annuloplasty. Note: No deformities and immobilization of the anterior mitral valve leaflet base
The placement of annuloplasty sutures within the annulus, towards the LV, and the second suture close to the first one, within the atrioventricular grove, does not present a higher risk of catching coronary vessels at any place of the mitral valve annulus. In the left fibrous trigone area, care has to be taken during suture placement because the aortic valve cusps are in the vicinity. Keeping the anterior mitral valve annulus free from any type of annuloplasty preserves the anterior mitral valve leaflet movement towards the posterior annulus during the beginning of LV systole. Such a double suture purse string annuloplasty can be easily controlled by performing hydraulic/water test before atrial closure and absolutely obligatory transesophageal echocardiography (TEE) after aortic cross clamp is released and the heart starts beating.
What might be unfavorable clinical situations for suture annuloplasty? In fact, the same TEE characteristics which are unfavorable for ring annuloplasty: MV leaflet coaptation depth ≥ 1 cm, mitral valve tenting area >2.5–3 cm2, high posterior leaflet tethering (postero-lateral angle >45°), interpapillary muscle distance >20 mm, posterior papillary muscle-right fibrous trigone distance >40 mm, basal lateral LV aneurysm (between mitral valve annulus and papillary muscle), global LV remodeling (LVEDD > 65 mm, LVESD > 51 mm, ESV > 140 ml), and systolic sphericity index > 0.7 [14].
Results
From our own series, we have analyzed 361 patients out of 518 in whom during the period of 1998–2011 we have performed suture annuloplasty along with CABG. The mean age of patients was 66.6 ± 9.4 years, mean NYHA class 2.8 ± 0.6, mean IMR grade 2.7 ± 0.5, mean LVEF 34.6 ± 10.7 %, mean LVEDDI 29.4 ± 4.8 mm/m2. One year mortality (including hospital mortality) was 13.6 %. Late mortality was 9.3 %.
At a mean follow-up of 43.2 months, LVEDDI increased by at least 10 % in 22.6 % of patients, and in 77.4 %, LVEDDI increased by less than 10 % or remained the same. Mild and/or trivial MR was observed in 85.5 % of patients, and in 14.5 % increased up to moderate/severe. There were stable changes in mitral valve annulus septolateral diameter within a group of patients without MR recurrence. Mitral valve septal-lateral diameters reduced from 38.09 ± 4.62 mm preoperatively to 23.92 ± 3.65 mm early postoperatively, and remained at a mean of 27.22 ± 4.26 mm 43.18 months after surgery. And in a group of patients with MR recurrence (IMR ≥ moderate), mean septal-lateral diameter reduced from 43.5 ± 5.32 mm preoperatively to 30.0 ± 6.25 mm early postoperatively, and remained at 30.6 ± 2.41 mm 43.18 months postoperatively.
However, not only mitral valve annulus diameter have played a role in IMR recurrence. We have found that in patients with mild to moderate MR, LVEDD was significantly higher in MV recurrence group (52.61 ± 5.04 mm vs 47.38 ± 2.82 mm, p = 0.014), LA diameter 45.29 ± 1.77 mm vs 38.92 ± 2.85, p < 0.001) and regional wall contraction index 1.76 ± 0.33 vs 1.51 ± 0.13, p = 0.032 (Table 11.1). While in a group of patients with mild MR, only LVEF was important with a p value < 0.05 in a MR recurrence group 38.24 ± 8.9 % vs 46.94 ± 4.76 % (Table 11.2).
Table 11.1
Echocardiographic changes in patients with moderate/severe MR
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