Totally Thoracoscopic Leaflet Folding, Multiple Artificial Chordae Implantation And Annuloplasty In Barlow Disease
Shengli Jiang, Sr., Lin Zhang, Lianggang Li, Tong Ren, Huimin Cui.
The Chinese PLA General Hospital, Beijing, China.
Background: Mitral valve repair for myxomatous Barlow disease is a challenging procedure requiring complex surgery with less than optimal results. This study aimed to confirm the safety and feasibility of totally thoracoscopic mitral valve procedure in Barlow disease by evaluating its early clinical outcomes.Methods: Recently we retrospectively analysed 10 consecutive totally thoracoscopic mitral valve procedure in Barlow disease in the latest 1 year. There were 2 women (20.0%) with a mean age of 33.5±11.0 (18-57) years. Preoperative echocardiography revealed all patients with excessive mitral leaflet tissue, billowing valves, and leaflet prolapse in 1 or both leaflets associated with severe MR. The procedures were performed via three small incisions and soft tissue retractors on the right side of the chest, and moderate hypothermic cardiopulmonary bypass (CPB) with cannulation of the femoral artery and femoral and internal jugular vein. In these cases, we routinely implanted 1 pair artificial chordae in P1 and P2 area respectively to shorten the subvalvular traction device to decrease the height of posterior leaflet at first, and folded the leaflets between the A3 and P3 area to reduce mitral leaflet surface area, and finally placed a 34mm Cosgrove annuloplasty band in the posterior to reduce of the size of the large hypokinetic annulus, sometimes we implanted multiple artificial chordae according to different pathological changes, even in the A1 and/or A2 area (Figure 1). Thus, the three pathologic components contributing to MR; namely the leaflets, annulus, and chordae or papillary muscle motion, were all surgically corrected to rebuild the mitral valve to a normal physiological state. Results: There was no operative or in-hospital mortality. The CPB and aortic cross clamp times were 194±36 min and 150±28 min, respectively. The ventilation time and intensive care unit stay length were 8.0± 3.3 h and 23± 2 h, respectively. Postoperational chest tube drainage in the first 48h was 230±41 ml. Intraoperative transoesophageal echocardiography (TEE) confirmed successful repair in all patients with no MR or systolic anterior motion (SAM). Up to now, all patients showed good cardiac function by echocardiography in recent follow-up interval (mean follow-up, 4.6±3.6 months; range, 1-12 months). Conclusion: The totally thoracoscopic procedure in Barlow disease by leaflet folding, multiple artificial chordae implantation and annuloplasty technique was technically feasible, safe, effective and reproducible in clinical practice. Although there was a concern regarding late postoperative mitral valve stenosis, further randomized and long-term follow-up studies were warranted to determine the clinical effects of this technique.
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