Alain Carpentier: I am very much impressed by this audience. If you think that a number of people, the best surgeons in the world, the best cardiologists, so that’s why I’m impressed. Now David asked me to talk about what he called “Revisiting the French Correction” and this is what I’m going to do.
The story begins in 1965 in Paris as you can see more precisely, at Hopital Broussais, a so called “Clinic Leriche”, where my mentor, Dubost, was the chief of the service. At that time, 1965, in our own service we used the first bubble oxygenator, which had been developed by Walton Lillehei. The type of surgery we did at that time, again I repeat 1965, was quite different than the ones we do today. There were only two different types of disease: one is congenital malformation and the second one is valve disease. As you can see, the valve disease themselves were quite different than what we see today with a predominant number of rheumatic valve disease. Valve reconstruction starts with rheumatic valve disease not with degenerative valve disease.
In those days the only solution available for the patients is Starr-Edwards Valve which saved thousands and thousands of patients. This approach was made by thrombo-embolism and the need for blood thinner with the morbidity of 1.5-15.7% per patient year depending upon the age and the patient’s condition and with the mortality of 1% per patient years. This adversely affected the quality of life of the patient. There was an alternative which was valve repair at that time. As you can see many techniques were developed, the most efficient being the one from McGoon with the leaflet plication of the P2 segment. The problem we could see was the fact that these techniques although they provided excellent results in many, many patients, they were proved to be unreliable. Progressively, they were abandoned at the expense, or the benefit, of mechanical valve replacement.
So I was really concerned by those problems, in particularly because I had been facing a few of my patient with the problem of cerebral emboli. So I told myself maybe we should revisit the concept of valve repair. What I found was the fact that, actually, the previous techniques aimed at repairing the mitral valve by just narrowing the annulus. They didn’t pay attention to the morphology, they didn’t pay attention to the function, they didn’t pay attention to the fact that there may have been several lesions or several dysfunctions. The predominant lesion, if I may say, as I saw it at that time, was the annular dilatation. As a result, most of these techniques aimed at reducing the size of the orifice, either by plicating the commissures, are indicated here, or by band.
So I went back to the laboratory and if I have an advice to give to the young surgeons in this room I would tell you there is always something to be done. There is always something to be improved. But what you have to do is go to the pathology, go to the anatomy, the fundamentals, those fundamentals are very important. Following this policy, what I found is that actually the annuls was deformed and not only dilated, but deformed. The geometry of the anterior leaflet was not the one we are accustomed to seeing with a reduction of the amount of tissue. This is obviously a rheumatic valve disease, and also there was a combination of dysfunction with the posterior leaflet tethered and the anterior leaflet, on the contrary, prolapsed. This is something which is true today, still true today. When you have a rheumatic valve, I heard this morning a case and it was very interesting for me because from the echo I could diagnose the association of the anterior leaflet prolapse, a tiny anterior leaflet prolapse, and a type 3 posterior leaflet to a restricted leaflet motion.
Now in a case like the one we saw this morning, presented by Dave, if you just repair one of the dysfunction, that is to say the annular dilatation of one lesion, then you are going to have an imperfect result and no surprise that this result is not going to last very long. So in other words, I don’t express myself very clearly, but it is just a clear recommendation is making sure to have a good valve analysis and then you will discover that rheumatic valve disease is a combination of the tiny prolapse of the anterior leaflet and a restrictive leaflet motion of the posterior leaflet. So if you repair those two dysfunctions then you can have a good results. If your valve analysis has not been appropriate and if you don’t repair those two dysfunctions and, of course, you have not going to have the same quality of the result.
Now the reconstructive valve surgery took place in 1968 by, you know, recognizing what I just said - the various dysfunctions and also the aim or the drawbacks of the existing techniques. Then based on these valve analysis came this idea of saying to myself normally we shouldn’t narrow the orifice, what should be done is remodeling the annulus. Remodeling the annulus was done this way, I’m sure you will remark, that this is not the normal shape that you would expect to have because this is a rheumatic valve disease where you have a small anterior leaflet. As a result, to compensate the reduction in height of the anterior leaflet, I did make this curvature to compensate this lack of tissue. The ring remodels the annulus, the ring remodels the commissures and the dilatation, which was found to take place at the annular dilatation, which was found to take place at the posterior aspect of the orifice was done by staged plications.
Following the introduction of the ring in 1968, pretty soon I found that it was necessary to develop adjunct techniques - Quadrangular Resection with Chordal Shortening, Chordal Transposition, Papillary Muscle Shortening, Sliding Leaflet technique, and then Physio ring - These allowed us to operate more patients as you can see, between 1970 and 1990. The number of valve reconstructions at Broussais rose dramatically allowing to operate more patients, but also more complex pathology as you can see here. As a result of the ring introduction in 1970 in the following 10 or 15 years we could see this incredible evolution with a mechanical valve used less and less frequently, including the Bjork-Shiely and even the Starr-Edwards valve, and the repair rising up and the bioprostheses in patients who couldn’t have valve repair. So I was asked, in 1983, I was asked by Frank Spencer to deliver the honored guest address at the American Association for Thoracic Surgery, which took place in Atlanta. I had the idea of using this term “The French Correction” and the reason was because at that time there was a movie, a very popular movie in the world, called the French Connection. It is not a big discovery to make the link between the two things, but at least it made the people laughing in the room. You should always try to have people laughing from time-to-time so please laugh from time-to-time. It gives us more confidence. So I’d like to draw your attention on these parts. New York, we are in New York, breeds tough cops. This is what the French Correction was all about.
The French Correction is not only having remodeling annuloplasty ring, I’m sure you know that you have heard that this morning, is obviously the basic concept which allowed all the other techniques to be developed. Not only the shape was important, but also a very precise approach with measurements of the different parts of the valve as you can see here. This technique is something of measuring or selecting the ring according to the amount of tissue is still the golden rule today. Note that the ring which used to be closed in the very beginning, is now in the second stage a few years after the introduction, began to be open to accommodate the subtle shape. The subtle shape the name did not exist, but actually we paid attention to the fact that very often the bulging of the anterior leaflet or the anterior annulus made necessary to open the ring and to bend the two extremities here.
So very soon it became very important to pay very much attention to the surface of coaptation. This is something which is very well known today, but it took some time to understand that, and particularly sometimes to understand that what you had to do is to restore a good surface of coaptation and not only a competent valve. In the same time, you know, it became obvious that the pathology as we knew it was more complicated than we thought. We particularly began to see a very curious disease, that which was not known at that time, although it had been described by Barlow, that is to say the billowing valve. The billowing valve is not a leaking valve, it is a malformation of the leaflet due to excess tissue and mitral regurgitation. We also insist in the fact that billowing valve can be associated with the prolapse, all things that you know very well today.
Basically, five years or six years after the introduction of the ring which again is a key allowing the development of all these techniques they were four fundamental approaches. The first, of course, is the annular remodeling, which is the most important one. Then, leaflet resection, which used to be either triangular or quadrangular; and chordae shortening after splitting the papillary muscle; and then valve mobilization by so called fenestration in Type III mitral regurgitation.
There were other techniques, as I said, which were developed and mainly the quadrangular resection and this has been discussed this morning, to avoid the curtain effect and excess tension on the free edge. That doesn’t mean that I renounce to the triangular resection that I developed with quadrangular just to avoid excess tension on the free edge. And that was something extremely interesting. The very first ruptured chordae that I could repair was this type where an adjacent chord could be used to reattached the free edge. This is still a technique which can be used very safely and it’s very easy which doesn’t need chordal replacement. The chordal transposition was, finally, the one we liked to use and which we still use today and this one has been abandoned, which is chordal shortening when you have elongated chordae.
I don’t want to be too long and I hope I don’t bother you, but I wanted to present to you the step-by-step the progress we have made in both the concept and the techniques. Again, I repeat this technique of chordal shortening, which was I would say very clever, I was very proud of this technique because it looked very nice. However, it has been abandoned because of chordal rupture following this repair. Type III is indicated here, I already mentioned.
Now, my title was “Revisiting the French Correction” a few words to make this second visit. Number one, I insist on the fact that pathology is very important. As you know, I like to make the distinction between Barlow and fibroelastic deficiency. Why? Number one because as surgeons, we know that these valves look very, very different. Who can say that this valve is the same pathology as the other one on the right. Obviously, it is a different disease. And the good news is that I was able to make the distinction between these two entities with a list of criteria which allowed this distinction and you will find them in the Journal of Thoracic and Cardiovascular Surgery 1980 as indicated here.
Why should we pay attention? Why should we make an effort to make this distinction? Why our cardiologists should give us, as surgeons, this information and give to the patient, the information? For the simple reason, which is the fact that this valve is very difficult to repair. You cannot guarantee to the patient that you are going to be successful unless, of course, you have a large expertise, as opposed to this one that is very simple to achieve. So if the cardiologist tells you or tells the patient don’t worry you have a fibroelastic deficiency with only Type II P2. It is going to be a very simple operation with an almost 99% chance of success. Totally different is a Barlow. That’s why it is important to make the distinction. Now the distinction is not always possible and for a reason which is very well illustrated here, although this is a fibroelastic deficiency as you can see, the tissue is transparent. In this area, which is dysfunctional, there is several lesions taking place and these P2 segment, although it used to be a fibroelastic deficiency, became progressively a thickened and normal and looked very much like mixed degeneration. So in nother words, when you make the diagnosis during the operation, don’t pay too much attention on the dsyfunctioning part, but on the well functioning part where you have the diagnosis.
Of course, valve analysis by echo was certainly a major step by making a very simple, a very complex story, and comparing or analyzing the different types. Those things are done. Today although not all the cardiologists pay attention to that, they may use, you know, curious terminology like flail leaflet or whatever and so it is so simple to classify the mitral valve dysfunction by one of the three types and some types are an association of Type II anterior leaflet and restricted leaflet motion of posterior leaflet.
Other changes have been taking place since 1995 and particularly the introduction of the so called Physio ring. Why did I introduce a new ring? Just because you remember that this ring, the so-called classic, was developed for rheumatic valve disease with anterior leaflet which had a reduced amount of tissue, as opposed to what was required by in degenerative valve disease where we could have a more sophisticated geometry of the ring with a larger orifice area and a subtle shape other than the one we were obliged to do with a classic ring. Another issue was the problem of SAM, which has been addressed with my colleague, Dr. Mihaileanu. We described the mechanism of SAM which is the posterior leaflet pushing the anterior leaflet towards the left arterial track and pretty soon it became obvious that SAM is due to excess tissue of the posterior segment in this particular.
Now, don’t think that SAM, when due to excess tissue, is always due to excess tissue of the P2 area. I have seen SAM due to excess tissue of P1, or excess tissue of P3. So when in the operating room you measure your different segment, don’t measure only the height of P2, but also the height of P1 and the height of P3 and if they measure more than 20 mm in height, you have to reduce the height. This was the result and the reason for the extensive sliding leaflet technique which allowed to reduce the height of the segment as indicated here and I insist on the fact that this is not a technique I use systematically, contrary to what has been said, I use it just whenever necessary and particularly very infrequently. As Dave said this morning, we like to preserve one in the patient to preserve the mobility, whereas we reduce the height of the P3 segment in this case if necessary.
The chordae introduced by Frater was certainly a step forward and I used them now that we know that it holds the test of time. We like also to use these papillary muscle repositioning which is a very elegant technique, as we indicated here, which allowed to correct a prolapse of a segment by bringing, at a lower level, the papillary muscle supporting the elongated chordae. Now a technique I like very much in particular in Barlow is papillary muscle shortening. I recognize that it is a little bit complex and frightening, but this is really an elegant technique and if you train yourself on a cadaver heart or pig heart before using it in clinical practice, then you will see the advantage. The advantage is as shortening is harmonious involving all the chordae all together.
And finally, rheumatic disease I really insisted on the fact that it is always the association of some degree of prolapse of the anterior leaflet and restricted leaflet motion of the posterior leaflet. Some degree of prolapse of the anterior leaflet and restricted leaflet motion. So if you want to repair and if you want to tell I have to repair this rheumatic valve disease, although it’s rheumatic valve disease, you should do it by restoring the surface of coaptation and there are techniques which could do that.
Finally, I insist on the fact that minimally invasive and robotic valve surgery for me important is the way to go because we should be as minimally invasive as possible and this is to recognize the effort of the pioneers in this field Hugo Vanerman and Randy Chitwood. So “Revisiting the French Correction” implies first giving up some techniques in the past: chordae shortening, very large systematic quadrangular resection when you have a P2 prolapse, but also adding new techniques: papillary muscle shortening, annular decalcification, techniques to deal with acute bacterial endocarditis. It implies adding techniques developed by others that are use today: artificial chordae, papillary muscle repositioning, commissural reconstruction, and also implies changing the indications at it has been emphasized today - early mitral valve repair to reduce the risk of the evolution, tricuspid annular dilatation is restrictive of regurgitation. All of these contributions have been for me very rewarding because they did respect the basic principles of valve reconstruction as did the French Connection. Now that is going to be my last slide and please don’t hesitate to laugh because there is some joke. So it was said in the movies, “New York breeds good cops” as you say, “and tough cops” and New York breeds good tough surgeons as well and David Adams is the toughest.
Thank you very much.
David Adams: Alain, I know that you have many, many awards in all of your travels in Societies and Academies but we have one for you here too and I know you are going to remember it today. We call it the Mitral Conclave Career Achievement Award and it has your name on it and there’s no one in the world that deserves it more than you. So thank you very much for the honor of being here today.
Carpentier: There is a glove as well. You didn’t mention the glove because he wants me to help tomorrow at the Mount Sinai Hospital. So I am prepared to do it or to help him. Thank you very much. Let me show it to the people. There it is.
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