Reductive annuloplasty with autopericardium in surgical treatment of mitral insufficiency

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Abstract

BACKGROUND: Despite the widespread usage of all-type rings in the surgical treatment of patients with mitral valve insufficiency (MV) and dilatation of its fibrous annulus, the researches on this topic are in progress.

AIM: To study the short- and long-term results of narrowing annuloplasty of the MV utilizing an autopericardium strip of calculated length.

MATERIALS AND METHODS: The study group consisted of 21 patients (average age 60.9 ± 4.3 years, women 23.8 %) with MV insufficiency of non-rheumatic ethiology. The narrowing of the fibrous annulus during valve reconstruction has been performed along with the posterior 2/3 of their circle using interrupted horizontal sutures. With those sutures, an autopericardial strip of the calculated length has been secured to the annulus. The length of the strip has been calculated according to the original method, according to the data obtained during preoperative transesophageal echocardiography. The length of the strip was 2/3π ∙ D (mm), where D — the existing length of the anterior leaflet of the MV in the middle portion from the fibrous annulus to the free edge in the zone of the A2 segment. The control group consisted of 38 patients with non-rheumatic MV insufficiency (average age 59.1 ± 3.5 years, women 23.7 %); the strengthening and narrowing of the fibrous annulus have been performed using a strip made from a wicker vascular prosthesis. The length was 55 mm, equal for all the patients. In both groups, in addition to the narrowing of the fibrous annulus, other types of mitral valve-sparing surgery (partial resection of MV leaflets, suture leaflets techniques, their combination) and combined procedures (coronary bypass surgery, left ventricle reconstructions for postinfarction aneurysms) have been also performed.

RESULTS: In the studied groups, the safety and reliability of the performed restrictive MV annuloplasty procedures have been demonstrated. During the follow-up period up to 8 years (average 3.5 ± 0.7 years), there was no recurrence of significant mitral regurgitation, which would require repeated surgery in both groups. Narrowing annuloplasty of the fibrous annulus of MV with a strip from the autopericardium of an individual calculated length allows to perform a more accurate anatomical correction of the valve compared with the control group. The existing methods of mitral annuloplasty, their advantages and disadvantages are discussed.

CONCLUSIONS: The proposed method of restrictive annuloplasty of the MV with an autopericardial strip of the calculated length allows to perform a reliable and safe correction of the dilated fibrous annulus in patients with mitral insufficiency during valve-preserving operations.

About the authors

Artem V. Sotnikov

North-Western State Medical University named after I.I. Mechnikov

Author for correspondence.
Email: artem.sotnikov@szgmu.ru
ORCID iD: 0000-0003-1831-7025

MD

Russian Federation, 41 Kirochnaya St., Saint Petersburg, 191015

Michail V. Melnikov

North-Western State Medical University named after I.I. Mechnikov

Email: memivik@yandex.ru
ORCID iD: 0000-0003-2215-3369

MD, Professor

Russian Federation, 41 Kirochnaya St., Saint Petersburg, 191015

Anna M. Bitieva

North-Western State Medical University named after I.I. Mechnikov

Email: anna.bitieva@szgmu.ru
ORCID iD: 0000-0002-5383-2367

MD

Russian Federation, 41 Kirochnaya St., Saint Petersburg, 191015

Eduard A. Kolmakov

North-Western State Medical University named after I.I. Mechnikov

Email: rectorat@szgmu.ru
ORCID iD: 0000-0002-0553-0081
Russian Federation, 41 Kirochnaya St., Saint Petersburg, 191015

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2. Fig. 1. Schematic illustration of a two-chamber plane of the heart when performing transesophageal echocardiography, necessary to determine the length of the median part of the anterior mitral valve leaflet: the measurement is carried out from the fibrous annulus to the free edge of the leaflet in the A2 segment. LV — left ventricle, LA — left atrium, ALMV — the anterior leaflet of the mitral valve

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3. Fig. 2. Mitral valve. Viewed from the operator’s side. There is a dilation of the fibrous annulus; the cusps do not close; lengthening of the P2 segment of the posterior cusp. Diagram of the anterior mitral valve leaflet: D — target fibrous annulus diameter after implantation of an autopericardial strip; ALMV — the anterior leaflet of the mitral valve; P1, P2, P3 — segments of the posterior leaflet of the mitral valve

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4. Fig. 3. Sutured mitral annulus and sutured autopericardial strip. The width of the strip is 5 mm; the length of the strip is calculated according to the formula. On the fibrous ring of the mitral valve, single horizontal sutures from a braided synthetic thread 2/0 are imposed, which are then sutured through a strip of autopericardium. Valvuloplasty in the form of resection of the lengthened P2 segment of the posterior leaflet of the MV is presented as an example of simultaneous intervention on the valves. ALMV — the anterior leaflet of the mitral valve; P1, P2, P3 — segments of the posterior leaflet of the mitral valve; AP — a strip from the autopericardium

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5. Fig. 4. An autopericardial strip is implanted; the interrupted sutures are tied. The final view of the mitral valve after correction of the concomitant pathology of the posterior leaflet (in this case, resection of the segment P2 of the posterior leaflet) and narrowing of the dilated fibrous annulus by implantation of a strip from the autopericardium of the estimated length. ALMV — the anterior leaflet of the mitral valve; P1, P2, P3 — segments of the posterior leaflet of the mitral valve; AP — a strip from the autopericardium

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Indexing metadata
6. Fig. 1. Schematic illustration of a two-chamber plane of the heart when performing transesophageal echocardiography, necessary to determine the length of the median part of the anterior mitral valve leaflet: the measurement is carried out from the fibrous annulus to the free edge of the leaflet in the A2 segment. LV — left ventricle, LA — left atrium, ALMV — the anterior leaflet of the mitral valve

Download (60KB)
Indexing metadata
7. Fig. 2. Mitral valve. Viewed from the operator’s side. There is a dilation of the fibrous annulus; the cusps do not close; lengthening of the P2 segment of the posterior cusp. Diagram of the anterior mitral valve leaflet: D — target fibrous annulus diameter after implantation of an autopericardial strip; ALMV — the anterior leaflet of the mitral valve; P1, P2, P3 — segments of the posterior leaflet of the mitral valve

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8. Fig. 3. Sutured mitral annulus and sutured autopericardial strip. The width of the strip is 5 mm; the length of the strip is calculated according to the formula. On the fibrous ring of the mitral valve, single horizontal sutures from a braided synthetic thread 2/0 are imposed, which are then sutured through a strip of autopericardium. Valvuloplasty in the form of resection of the lengthened P2 segment of the posterior leaflet of the MV is presented as an example of simultaneous intervention on the valves. ALMV — the anterior leaflet of the mitral valve; P1, P2, P3 — segments of the posterior leaflet of the mitral valve; AP — a strip from the autopericardium

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9. Fig. 4. An autopericardial strip is implanted; the interrupted sutures are tied. The final view of the mitral valve after correction of the concomitant pathology of the posterior leaflet (in this case, resection of the segment P2 of the posterior leaflet) and narrowing of the dilated fibrous annulus by implantation of a strip from the autopericardium of the estimated length. ALMV — the anterior leaflet of the mitral valve; P1, P2, P3 — segments of the posterior leaflet of the mitral valve; AP — a strip from the autopericardium

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Copyright (c) 2021 Sotnikov A.V., Melnikov M.V., Bitieva A.M., Kolmakov E.A.

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