How to Do it
Ring-Noose-String Technique Allows Adjustable Papillary Muscle Repositioning During Minimally Invasive Mitral Valve Repair in Patients with Functional/Ischemic Mitral Regurgitation Wolfgang Bothe1,2
Torsten Doenst2
1 Department of Cardiovascular Surgery, Heart Center Freiburg, Bad
Krozingen, Freiburg, Germany 2 Department of Cardiothoracic Surgery, Jena University Hospital, Jena, Germany
Address for correspondence Wolfgang Bothe, MD, Department of Cardiothoracic Surgery, Jena University Hospital, Erfurter Allee 101, Jena 07740, Germany (e-mail: [email protected]).
Abstract
Keywords
► mitral valve surgery ► heart failure ► minimally invasive surgery
In patients with functional/ischemic mitral regurgitation (FMR/IMR), mitral annuloplasty alone frequently results in recurrent regurgitation because of ongoing left ventricular dilatation and recurrent leaflet tethering. Adjunctive subvalvular approaches exist, but the technical shortcomings limit their clinical acceptance. A novel adjunctive technique was applied in three patients: A polytetrafluoroethylene string and noose were anchored to the posteromedial and anterolateral papillary muscle, respectively. The string ends were guided through the noose, exteriorized through the midposterior annulus into the left atrium, and length-adjusted during the saline test. The procedure allowed safe and straightforward papillary muscle repositioning and may stabilize repair results in FMR/IMR patients.
Introduction Experimental studies have suggested a septolateral mitral annular dilatation as well as a lateral displacement of the posteromedial papillary muscle (PM) as predominant mechanisms leading to functional/ischemic mitral regurgitation (FMR/IMR).1 In these patients, surgical mitral valve repair using a ring annuloplasty alone is associated with recurrent mitral regurgitation (MR) rates of 30%.2 Two of the following main reasons may account for these dismal results: First, annuloplasty ring implantation may enhance leaflet tethering, hamper optimal leaflet coaptation and, thus, result in residual MR after annuloplasty. Second, ongoing left ventricular (LV) dilatation after valve repair may lead to further PM displacement, increased leaflet tethering, and recurrent MR.3 As a consequence, several adjunctive techniques have been developed that aim to counteract the associated PM displacement. However, none of these techniques have gained
received November 24, 2014 accepted after revision January 12, 2015
widespread clinical acceptance. Possible reasons may be that the techniques described are technically complex, do not allow a modification of the subvalvular geometry under conditions where the valve is closed, require a full median sternotomy, or all of the aforementioned factors. We developed and applied a novel adjunctive subvalvular technique in the three patients with FMR/IMR that allowed safe and straightforward adjustment of the interpapillary distance during the saline test.
Technique Description After opening of the left atrium, the PMs are identified. A feltenforced 3-CV polytetrafluoroethylene (PTFE) noose (3 mm in diameter) is sewn to the base of the anterolateral PM (►Fig. 1A) and a double-armed, felt-enforced 3-CV PTFE string is sutured to the base of the posteromedial PM (►Fig. 1B). The ends of the PTFE string are guided through
© Georg Thieme Verlag KG Stuttgart · New York
DOI http://dx.doi.org/ 10.1055/s-0035-1549264. ISSN 0171-6425.
Downloaded by: University of Iowa Libraries. Copyrighted material.
Thorac Cardiovasc Surg
Bothe, Doenst
Fig. 1 Intraoperative images of the Ring-Noose-String-technique applied in one representative patient: A PTFE noose (3 mm in diameter) is sewn to the base of the anterolateral papillary muscle (A, circle) and a double-armed PTFE string to the base of the posteromedial papillary muscle (B, asterisk). The ends of the string are guided through the noose (so that a pull on the string relocates the posteromedial toward the anterolateral papillary muscle) and exteriorized into the left atrium through the posterior mitral annulus behind the P2 segment of the posterior mitral leaflet (C). After ring implantation, the saline test is performed, the string length is adjusted, and the string ends are tied to the annuloplasty ring (D, arrow) when the coaptation point is beginning to increase (see ►Video 1).
the noose, so that pulling on the PTFE string results in a repositioning of the posteromedial PM toward the anterolateral PM. The string is exteriorized into the left atrium through the midposterior mitral annulus behind the posteri-
or leaflet at the level of P2 (►Fig. 1C). Here, attention is required to avoid tangling of the PTFE strings with primary order chords. After string exteriorization, the annuloplasty ring is implanted in a regular fashion and the ends of the PTFE
Fig. 2 Schematic illustration of the Ring-Noose-String technique. APM, anterior papillary muscle; PPM, posterior papillary muscle; P2, midposterior annular segment. Thoracic and Cardiovascular Surgeon
Downloaded by: University of Iowa Libraries. Copyrighted material.
Ring-Noose-String Technique
Ring-Noose-String Technique
Video 1 Video demonstrating the surgical technique and preoperative and postoperative echocardiogram in one representative patient. Online content including video sequences viewable at: https://www.thieme-connect.com/products/ ejournals/html/doi/10.1055/s-0035-1549264.
Whereas in one patient a full median sternotomy was performed, the other two patients underwent minimally invasive mitral valve repair via a right minithoracotomy. All patients received size 26-mm annuloplasty rings (CarpentierEdwards Physio, Edwards Lifesciences, Irvine, California, United States). Aortic cross-clamp times were 46, 65, and 66 minutes. The procedure was performed without any complications. The postoperative recovery was uneventful in all patients (length of intensive care unit stay was 5 days in two patients and 1 day in the other patient) with no relevant residual MR (MR grade 0.5, 0 and 0.5 at 11, 6 and 5 days after surgery, respectively). A pre- and postoperative echocardiogram of one representative patient is shown in ►Video 1.
ing valve repair.4 However, currently proposed techniques may be technically complex5 and/or do not allow a dynamic adjustment of the PM positions when the LV is filled, the annuloplasty ring implanted and the mitral valve is closed. To account for the latter shortcoming, Langer et al introduced a technique that allows a PM repositioning in the beating heart using a PTFE string anchored to the posteromedial PM. This technique, however, requires opening of the aorta and a full median sternotomy to control the exteriorization of the PTFE string.4 In an attempt to improve this approach, we have developed a novel PM repositioning technique that allows an adjustable PM repositioning during the saline test. Our results demonstrate that the Ring-Noose-String technique is safe and straightforward independent of the surgical access used (sternotomy vs. minimally invasive approach). Long-term followup and larger patient numbers are necessary to demonstrate whether this technique helps to improve outcomes in patients with FMR/IMR undergoing valve repair.
References 1 Tibayan FA, Rodriguez F, Zasio MK, et al. Geometric distortions of
2
3
4
Discussion Initial studies have demonstrated that the application of subvalvular techniques in addition to annuloplasty may provide a durable correction in patients with FMR/IMR undergo-
5
the mitral valvular-ventricular complex in chronic ischemic mitral regurgitation. Circulation 2003;108(Suppl 1):II116–II121 Acker MA, Parides MK, Perrault LP, et al; CTSN. Mitral-valve repair versus replacement for severe ischemic mitral regurgitation. N Engl J Med 2014;370(1):23–32 Hung J, Papakostas L, Tahta SA, et al. Mechanism of recurrent ischemic mitral regurgitation after annuloplasty: continued LV remodeling as a moving target. Circulation 2004;110(11, Suppl 1): II85–II90 Langer F, Kunihara T, Hell K, et al. RINGþSTRING: Successful repair technique for ischemic mitral regurgitation with severe leaflet tethering. Circulation 2009;120(11, Suppl):S85–S91 Menicanti L, Di Donato M, Frigiola A, et al; RESTORE Group. Ischemic mitral regurgitation: intraventricular papillary muscle imbrication without mitral ring during left ventricular restoration. J Thorac Cardiovasc Surg 2002;123(6):1041–1050
Thoracic and Cardiovascular Surgeon
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string are loosely stitched through the ring. The saline test is performed, the string ends are pulled and tied to the annuloplasty ring (►Fig. 1D) when the coaptation point is beginning to increase (see ►Video 1). ►Fig. 2 shows a schematic of the applied surgical technique.
Bothe, Doenst
Ring-Noose-String Technique Allows Adjustable Papillary Muscle Repositioning During Minimally Invasive Mitral Valve Repair in Patients with Functional/Ischemic Mitral Regurgitation Wolfgang Bothe1,2
Torsten Doenst2
1 Department of Cardiovascular Surgery, Heart Center Freiburg, Bad
Krozingen, Freiburg, Germany 2 Department of Cardiothoracic Surgery, Jena University Hospital, Jena, Germany
Address for correspondence Wolfgang Bothe, MD, Department of Cardiothoracic Surgery, Jena University Hospital, Erfurter Allee 101, Jena 07740, Germany (e-mail: [email protected]).
Abstract
Keywords
► mitral valve surgery ► heart failure ► minimally invasive surgery
In patients with functional/ischemic mitral regurgitation (FMR/IMR), mitral annuloplasty alone frequently results in recurrent regurgitation because of ongoing left ventricular dilatation and recurrent leaflet tethering. Adjunctive subvalvular approaches exist, but the technical shortcomings limit their clinical acceptance. A novel adjunctive technique was applied in three patients: A polytetrafluoroethylene string and noose were anchored to the posteromedial and anterolateral papillary muscle, respectively. The string ends were guided through the noose, exteriorized through the midposterior annulus into the left atrium, and length-adjusted during the saline test. The procedure allowed safe and straightforward papillary muscle repositioning and may stabilize repair results in FMR/IMR patients.
Introduction Experimental studies have suggested a septolateral mitral annular dilatation as well as a lateral displacement of the posteromedial papillary muscle (PM) as predominant mechanisms leading to functional/ischemic mitral regurgitation (FMR/IMR).1 In these patients, surgical mitral valve repair using a ring annuloplasty alone is associated with recurrent mitral regurgitation (MR) rates of 30%.2 Two of the following main reasons may account for these dismal results: First, annuloplasty ring implantation may enhance leaflet tethering, hamper optimal leaflet coaptation and, thus, result in residual MR after annuloplasty. Second, ongoing left ventricular (LV) dilatation after valve repair may lead to further PM displacement, increased leaflet tethering, and recurrent MR.3 As a consequence, several adjunctive techniques have been developed that aim to counteract the associated PM displacement. However, none of these techniques have gained
received November 24, 2014 accepted after revision January 12, 2015
widespread clinical acceptance. Possible reasons may be that the techniques described are technically complex, do not allow a modification of the subvalvular geometry under conditions where the valve is closed, require a full median sternotomy, or all of the aforementioned factors. We developed and applied a novel adjunctive subvalvular technique in the three patients with FMR/IMR that allowed safe and straightforward adjustment of the interpapillary distance during the saline test.
Technique Description After opening of the left atrium, the PMs are identified. A feltenforced 3-CV polytetrafluoroethylene (PTFE) noose (3 mm in diameter) is sewn to the base of the anterolateral PM (►Fig. 1A) and a double-armed, felt-enforced 3-CV PTFE string is sutured to the base of the posteromedial PM (►Fig. 1B). The ends of the PTFE string are guided through
© Georg Thieme Verlag KG Stuttgart · New York
DOI http://dx.doi.org/ 10.1055/s-0035-1549264. ISSN 0171-6425.
Downloaded by: University of Iowa Libraries. Copyrighted material.
Thorac Cardiovasc Surg
Bothe, Doenst
Fig. 1 Intraoperative images of the Ring-Noose-String-technique applied in one representative patient: A PTFE noose (3 mm in diameter) is sewn to the base of the anterolateral papillary muscle (A, circle) and a double-armed PTFE string to the base of the posteromedial papillary muscle (B, asterisk). The ends of the string are guided through the noose (so that a pull on the string relocates the posteromedial toward the anterolateral papillary muscle) and exteriorized into the left atrium through the posterior mitral annulus behind the P2 segment of the posterior mitral leaflet (C). After ring implantation, the saline test is performed, the string length is adjusted, and the string ends are tied to the annuloplasty ring (D, arrow) when the coaptation point is beginning to increase (see ►Video 1).
the noose, so that pulling on the PTFE string results in a repositioning of the posteromedial PM toward the anterolateral PM. The string is exteriorized into the left atrium through the midposterior mitral annulus behind the posteri-
or leaflet at the level of P2 (►Fig. 1C). Here, attention is required to avoid tangling of the PTFE strings with primary order chords. After string exteriorization, the annuloplasty ring is implanted in a regular fashion and the ends of the PTFE
Fig. 2 Schematic illustration of the Ring-Noose-String technique. APM, anterior papillary muscle; PPM, posterior papillary muscle; P2, midposterior annular segment. Thoracic and Cardiovascular Surgeon
Downloaded by: University of Iowa Libraries. Copyrighted material.
Ring-Noose-String Technique
Ring-Noose-String Technique
Video 1 Video demonstrating the surgical technique and preoperative and postoperative echocardiogram in one representative patient. Online content including video sequences viewable at: https://www.thieme-connect.com/products/ ejournals/html/doi/10.1055/s-0035-1549264.
Whereas in one patient a full median sternotomy was performed, the other two patients underwent minimally invasive mitral valve repair via a right minithoracotomy. All patients received size 26-mm annuloplasty rings (CarpentierEdwards Physio, Edwards Lifesciences, Irvine, California, United States). Aortic cross-clamp times were 46, 65, and 66 minutes. The procedure was performed without any complications. The postoperative recovery was uneventful in all patients (length of intensive care unit stay was 5 days in two patients and 1 day in the other patient) with no relevant residual MR (MR grade 0.5, 0 and 0.5 at 11, 6 and 5 days after surgery, respectively). A pre- and postoperative echocardiogram of one representative patient is shown in ►Video 1.
ing valve repair.4 However, currently proposed techniques may be technically complex5 and/or do not allow a dynamic adjustment of the PM positions when the LV is filled, the annuloplasty ring implanted and the mitral valve is closed. To account for the latter shortcoming, Langer et al introduced a technique that allows a PM repositioning in the beating heart using a PTFE string anchored to the posteromedial PM. This technique, however, requires opening of the aorta and a full median sternotomy to control the exteriorization of the PTFE string.4 In an attempt to improve this approach, we have developed a novel PM repositioning technique that allows an adjustable PM repositioning during the saline test. Our results demonstrate that the Ring-Noose-String technique is safe and straightforward independent of the surgical access used (sternotomy vs. minimally invasive approach). Long-term followup and larger patient numbers are necessary to demonstrate whether this technique helps to improve outcomes in patients with FMR/IMR undergoing valve repair.
References 1 Tibayan FA, Rodriguez F, Zasio MK, et al. Geometric distortions of
2
3
4
Discussion Initial studies have demonstrated that the application of subvalvular techniques in addition to annuloplasty may provide a durable correction in patients with FMR/IMR undergo-
5
the mitral valvular-ventricular complex in chronic ischemic mitral regurgitation. Circulation 2003;108(Suppl 1):II116–II121 Acker MA, Parides MK, Perrault LP, et al; CTSN. Mitral-valve repair versus replacement for severe ischemic mitral regurgitation. N Engl J Med 2014;370(1):23–32 Hung J, Papakostas L, Tahta SA, et al. Mechanism of recurrent ischemic mitral regurgitation after annuloplasty: continued LV remodeling as a moving target. Circulation 2004;110(11, Suppl 1): II85–II90 Langer F, Kunihara T, Hell K, et al. RINGþSTRING: Successful repair technique for ischemic mitral regurgitation with severe leaflet tethering. Circulation 2009;120(11, Suppl):S85–S91 Menicanti L, Di Donato M, Frigiola A, et al; RESTORE Group. Ischemic mitral regurgitation: intraventricular papillary muscle imbrication without mitral ring during left ventricular restoration. J Thorac Cardiovasc Surg 2002;123(6):1041–1050
Thoracic and Cardiovascular Surgeon
Downloaded by: University of Iowa Libraries. Copyrighted material.
string are loosely stitched through the ring. The saline test is performed, the string ends are pulled and tied to the annuloplasty ring (►Fig. 1D) when the coaptation point is beginning to increase (see ►Video 1). ►Fig. 2 shows a schematic of the applied surgical technique.
Bothe, Doenst
