In this video we are going to show five different cases of leaflet reconstruction with Glutaraldehyde-fixed pericardium and complex mitral valve repair.
The first case is a 53-year-old woman with Oxacillin-resistant Staphylococcus aureus and severe mitral regurgitation under antibiotic therapy. The echo shows severe mitral regurgiation and the pathology correlates with a windsock deformity of the anterior leaflet and a clear perforation near the base of A3. We start by wide debridement of the anterior leaflet including erythematous tissue in the perforation. This is continued around to the marginal chordae. To take advantage of the defect, we place ring sutures in the annulus, and then we are going to select and fashion a piece of her pericardium after it has been fixed for approximately 10 minutes with 0.625% glutaraldehyde. You can see we are catching it with 4-0 Prolene with an RB needle. The patch should be slightly larger than the size of the defect to account for the 2 mm decrease in height from your bites of the suture. Here you can see the final patch. You should size the ring in a typical fashion, and in this case since this is a very small patient, she sizes to a 24 based on her anterior leaflet surface area, and here is the final reconstruction on the saline test with a good closure line. You can see we are going to do an ink test. We are going to cover the closure line with ink which will allow us to look at the amount of coaptation. You see the patch is part of the coaptation zone and the final echocardiogram with no mitral regurgitation.
The second case is a 40-year-old woman with a murmur since childhood. She had severe mitral regurgitation and congestive heart failure during her pregnancy. She has a restricted leaflet motion and currently only mild mitral regurgitation. She wants to get pregnant again. We have operated on her, and you can see she has a congenitally abnormal valve with minimal tissue. She has several frozen chordae to her leaflet and a diminutive posterior leaflet. We are going to begin by mobilizing the anterior leaflet taking these very thickened, chords off the margin. You can see this chord is almost 4 mm thick. So after removing these restricted secondary chords, I also had to take the papillary muscle off in places directly from the leaflet. Once full mobilization of the leaflet is done, we now increase the surface area of the posterior leaflet. You can see how the traction sutures in the marginal chordae and I am now dividing the posterior leaflet from the base of the posterior annulus. We are now going to take a piece of her own pericardium, fixed in glutaraldehyde, and increase the overall height and surface area of the posterior leaflet to approximately 1.5 cm. You can see here after a running suture as we anastomose the patch into the posterior leaflet and good coaptation surface. In this case, we have used the classic ring and you can see the final saline test with good apposition of the tissue and again the patch, forming part of the coaptation surface. Postoperative echocardiogram shows a long line of coaptation and absent residual mitral regurgitation.
The third case is a 51-year-old man who is six months following CABG and mitral valve repair for fibroelastic deficiency at an outside hospital. He developed early severe recurrent MR. Here you can see he has had a dehiscence of his posterior leaflet suture line. This patient had a quadrangular resection and a running suture closure and you can see it is disrupted. To do a mitral re-repair, you need to sharply excise the ring preserving the annulus. I like to get behind the ring and take it out as you see by cutting the individual sutures, lifting it carefully so as not to damage the leaflet or the hinge area. In this case, with the lack of tissue I am going to detach the remaining P3 segment, and now you can see the margin somewhat distended, so I am going to connect the margin of the residual P2 and residual P3 with an interrupted suture. Now, we are going to do a patch augmentation of the body of the posterior leaflet, so again we have taken the glutaraldehyde piece of pericardium. There you can see it sewn into the leaflet to increase the overall height to approximately 1.5 cm. After a true size ring you can see out an excellent closure line and good surface of coaptation. The postoperative echocardiogram shows absent residual mitral regurgitation.
The next case is a 49-year-old male with a history of partial AV canal repair as an infant. He had a second re-repair 20 years later, and now presents for class III heart failure and refusing to take Coumadin. We are determined to do a third time re-repair. You can see has calcified cleft and calcified patch. It is important in a case like this to remove all of the calcium as a first step. You can see a rock hard anterior leaflet. There is a sharp debridement of the calcified cleft and patch. It is important in re-operations to resect all the immobile tissue and then make a decision whether reconstruction is feasible. Here you can see we are taking off the rest of this calcified area creating a huge defect in the anterior leaflet. Now, the margin is distended, so I am going to close the margin together preserving the marginal chordae, and in this case, I like to perform a pulley system into the atrial wall to put the anterior leaflet under tension for patch augmentation. Now, we are going to use a piece of the patient’s glutaraldehyde-fixed pericardium. You can see in this case I have used an RB needle to drive it through the remaining calcified patch near the annulus, and you really want to oversize this patch a little bit because you are losing length as you take your bites into it and then you also want to protect the patient from later shrinkage, so you can see I usually start superiorly and run it around. Here is the final result with a long line of coaptation and an excellent closure line on echo.
The final case is a very complicated patient. A 21-year-old woman with congenital mitral valve stenosis. She is New York Heart Association class III and has a resting mitral valve gradient of approximately 12. You can see she has a parachute mitral valve. This is her central orifice, a parachute anterior papillary muscle apparatus. We start with a commissurotomy and wide resection of the posterior commissure to the middle of the anterior leaflet. We are going to have to resect the calcified P2 and P3 segment. A chordal fenestration of her only parachute chord. This is done sharply taking a wedge of tissue out. This will mobilize the chordal apparatus to her anterior leaflet. Now, you can see what we are left with. We need to replace almost half of her valve. She has no chordal support to the medial half of her valve. Here is the patch sewn in to the posterior leaflet. We are now going to re-suspend the support with several Gore-Tex chords. You can note that I am taking imbricating bites to create a rough zone in the leaflet after attaching the Gore-Tex chords into the base of the papillary, or into the head of papillary muscle. So we tie these down to creating a rough zone and then re-suspending the edge. She needs several of these to support both the pre-margin of the patch which has no support as well as her anterior leaflet. Again, you can see this imbricating bite to create a rough zone. Now under saline testing, you'll see a leak at the commissure. This always happens when you do a patch extension into the commissural area. It is important to recreate the commissure with a magic suture. That's a Lembert suture and imbricating suture in the case in the body and near the free edge, then through your free edge, and through the body, and as you tie this, it rolls the commissure and inverts it to create a coaptation surface. Here is the final reconstruction with several Gore-Tex chords and two magic sutures and a fenestrated papillary head, and here is the final result with the saline test, good coaptation and the final echo shows no regurgitation and a resting mean gradient of 2.
In this video, I hope we have been able to demonstrate how pericardial patch reconstruction will allow you to perform very complex mitral valve repair.
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(Video length: 9:26)
