Nonresectional Posterior Leaflet Remodeling Through Free Margin Running Suture For Minimally Invasive Mitral Repair
Alfonso Agnino1, Giovanni Albano2, Antonino Piti'3, Matteo Parrinello2, Paolo Panisi3, Amedeo Anselmi1.
1Division of Minimally Invasive Cardiac Surgery, Cliniche Humanitas Gavazzeni, Bergamo, Italy, Bergamo, Italy, 2Division of Cardiac Anesthesia, Cliniche Humanitas Gavazzeni, Bergamo, Italy, Bergamo, Italy, 3Cardiovascular Department, Cliniche Humanitas Gavazzeni, Bergamo, Italy, Bergamo, Italy.
OBJECTIVE: We aimed at illustrating a novel technique for nonresectional posterior leaflet remodeling to achieve minimally invasive mitral valve repair in degenerative disease. Previously reported strategy for nonresectional leaflet remodeling are based on ventricularization of the excess leaflet tissue. Nonetheless, such strategy may be limited in case of large amount of redundant tissue and multi-segment prolapse. The technique presented herein is aimed at overcoming such limitations.
METHODS: The technique is presented in Video 1 (endoscopic view). Patient is a 56 years-old lady with severe mitral regurgitation and normal left ventricular function. Minimally invasive mitral repair was indicated; the approach was through a 4-cm right minithoracotomy (4th intercostal space) with endo-clamping (HeartPort). At valve analysis, a prolapse with large amount of excess tissue of P2 and P3 segments with chordal elongation and rupture was evidenced. The P1 segment was normal in height and morphology, and no alterations were evident for the anterior leaflet. A continuous Gore-Tex 4-0 suture was passed at the level of the free margin of the posterior leaflet, starting from the prolapsing edge of P3, through P2 and until the midportion of P1. The suture was tied at P1, and residual leaks between P2 and P3 were corrected by Gore-Tex suture. Hence, the prolapsing tissue was compelled at the P1 height and redistributed over the length of the posterior leaflet, with ensuing coaptation. Complete annuloplasty was performed. Requirements for this technique are large prolapsing area (mainly if exceeding P2) and redundant tissue, normal P1 (or P3 for inversed technique), and avoidance of undersized annuloplasty to minimize the risk of SAM.
RESULTS: Saline test showed good valve continence and morphology. Transesophageal echocardiography showed absent residual regurgitation. Pre-discharge transthoracic echocardiography confirmed this finding with normal transvalvular gradients.
CONCLUSIONS: Due to its straightforward application, nonresectional leaflet remodeling with free margin running suture is particularly suited for minimally invasive surgery, in favorable anatomic conditions. It avoids leaflet resection and more complex, time-consuming techniques. Compared to previously reported methods, the technique illustrated herein is adaptable to a larger array of leaflet lesions, namely in case of large prolapse extending beyond P2.
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