International Journal of Cardiology 186 (2015) 16–18
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Non-resectional leaflet remodeling mitral valve repair preserves leaflet mobility: A quantitative echocardiographic analysis of mitral valve configuration☆ Yasuhiro Shudo a, Jeffrey E. Cohen a,b, John W. MacArthur a,b, Andrew B. Goldstone a,b, Arudo Hiraoka b, Jessica Howard b, Alexander S. Fairman b, Jay Patel a, Bryan B. Edwards a, Pavan Atluri b, Y. Joseph Woo a,⁎ a b
Department of Cardiothoracic Surgery, Stanford University School of Medicine, United States Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania School of Medicine, United States
a r t i c l e
i n f o
Article history: Received 23 February 2015 Accepted 17 March 2015 Available online 18 March 2015 Keywords: Mitral regurgitation Mitral valve repair Echocardiography
Several studies have shown the mitral repair technique to be effective and safe for mitral regurgitation (MR) [1–5]. The classic quadrangular resection has become a highly reproducible approach with great long-term durability for treating MR [5]. Evolving from the classic repair, we have described a non-resectional leaflet remodeling mitral valve repair technique, in which the prolapsed leaflet tissue is inverted into the left ventricle (LV) to eliminate prolapse while maximizing leaflet surface for coaptation and preserving leaflet mobility [2,6]. This technique avoids the potential negatives of leaflet resection and neochords. Interestingly, post-repair mitral leaflet and annular geometry have yet to be fully quantified. Trans-esophageal echocardiography (TEE) [7,8] effectively assesses mitral valve geometry in the setting of different forms of mitral valve pathology and complex valve disease. In the present study, we evaluated the configuration of the mitral valve before and after mitral valve repair utilizing TEE. Between October 2010 and October 2012, 81 mitral valve operations performed at the University of Pennsylvania Health System were reviewed. This study was approved by the Institutional Review Board of the University of Pennsylvania IRB (Protocol number: 810968). The study population was limited to 59 patients who underwent TEE before
☆ Presented at the Southern Thoracic Surgical Association 60th Annual Meeting, Scottsdale, AZ, October 30–November 2, 2013. ⁎ Corresponding author at: 300 Pasteur Drive, Falk Cardiovascular Research Center, Stanford University School of Medicine, Stanford, CA 94305, United States. E-mail address: [email protected] (Y.J. Woo).
http://dx.doi.org/10.1016/j.ijcard.2015.03.239 0167-5273/© 2015 Elsevier Ireland Ltd. All rights reserved.
and after the operation. Of those, 33 patients underwent the nonresectional leaflet remodeling and 26 underwent the standard quadrangular resection with reapproximation for degenerative MR. The patients' baseline characteristics are presented in Table 1. In the leaflet remodeling group, the prolapsed portions were P2 (n = 23); P2/P3 (n = 4); P1/P2 (n = 4); P3 (n = 2). Briefly, the prolapsed segment is retracted into the atrium to reveal the LV endocardium, and a CV5 Gore-Tex suture is passed into the myocardium. The leading edge is inverted into LV, imbricating a portion of the leaflet and generating two near-apposing tissue folds emanating radially. These folds are sutured together with the Gore-Tex suture, thereby fixating the prolapsed leaflet tissue into the ventricular side and generating a smooth coaptation surface in the correct plane. In the quadrangular resection group, mitral valve repair is performed using the standardized technique. All patients tolerated the operation well. Intra-operative data are presented in Table 2. The comprehensive TEE examination was performed using the X4 matrix array transducer (iE33, Philips Medical Systems) in all 59 patients. Intra-operative TEE was conducted before sternotomy and after termination of cardiopulmonary bypass. All patients were with grade 3 or greater MR. Postoperatively, all patients showed MR equal to or less than grade 1, and the severity score decreased significantly, from 3.5 ± 0.7 to 0.2 ± 0.4 after leaflet remodeling, and from 3.5 ± 0.7 to 0.3 ± 0.6 after quadrangular resection. A four-chamber view was utilized for data acquisition. The imaging plane cuts the coaptation line perpendicularly, transecting P2 and A2. The measured variables were the annular antero-posterior dimension and coaptation length at midsystole. The annular antero-posterior dimension was measured as the distance between the center of the anterior and posterior mitral annulus at mid-systole. The coaptation length was obtained by tracing the coapted leaflets between the coaptation point of both leaflets and the tip of leaflet at mid-systole. Coaptation length index was defined as the ratio of the coaptation length to the annular anterior–posterior dimension [7]. The anterior and posterior mitral leaflet excursions were calculated using the following formula; α2 − α1 and β2 − β1 (Fig. 1). The annular antero-posterior dimension was significantly decreased in both groups. The coaptation length and coaptation length index were significantly increased in both groups. The anterior leaflet excursion remained unchanged in both groups. The posterior leaflet
Y. Shudo et al. / International Journal of Cardiology 186 (2015) 16–18
17
Table 1 Patient characteristics. Variables
Females, n (%) Age, y LVEF (%) Hypertension, n (%) Diabetes mellitus, n (%) Hyperlipidemia, n (%) Cerebrovascular disease, n (%) Atrial fibrillation/flutter, n (%) Smoking history, n (%)
Leaflet remodeling
Quadrangular resection
(n = 33)
(n = 26)
21 (64) 62 ± 10 59 ± 12 15 (45) 1 (3) 13 (39) 1 (3) 6 (18) 17 (52)
15 (58) 66 ± 14 55 ± 14 9 (35) 2 (8) 4 (15) 0 (0) 12 (46) 5 (19)
Data are presented as mean value ± SD or no. of patients (%).
excursion was preserved in the leaflet remodeling group, while it was greatly diminished in the quadrangular resection group (Fig. 2). In the between-group comparisons, the average change in the coaptation length tended to be larger in the leaflet remodeling group. Moreover, the average change in the posterior leaflet excursion was greater in the quadrangular resection group than in the leaflet remodeling group. This trend probably stems from the different surgical approaches, and suggests the leaflet remodeling may be beneficial in some cases (Fig. 3). Statistical calculations were performed using the JMP 9.0 (SAS Institute Inc.). Continuous variables are expressed as the mean ± SD. Comparisons were made using the Wilcoxon–Mann–Whitney U test. Categorical variables were compared by chi square test and the Fisher exact test. A P-value less than .05 was considered to be statistically significant. This study demonstrated the quantitative echocardiographic analysis of mitral valve configuration following either leaflet remodeling or quadrangular resection. The detailed quantitative analysis showed a significant decrease in the annular antero-posterior dimension and a remarkable increase in the leaflet coaptation length in both study groups, with the increase in coaptation length tending to be larger in the leaflet remodeling group. The data clearly illustrate the preservation of the anterior leaflet excursion following either leaflet remodeling or quadrangular resection. Importantly, however, the posterior leaflet excursion was preserved after leaflet remodeling, while it was greatly
Table 2 Surgical data. Variables
Leaflet remodeling
Quadrangular resection
(n = 33)
(n = 26)
Non-resectional leaflet remodeling, n (%) Quadrangular resection with reapproximation, n (%) Annuloplasty ring size used Minimally invasive approach, n (%) Concomitant procedures CABG, n (%) ASD, n (%) PFO, n (%) TAP, n (%) Maze, n (%) Intraoperative data CPB time, min AXC time, min
33 (100) 0 (0) 31 ± 3 24 (73)
0 (0) 26 (100) 32 ± 4 0 (0)
1 (3) 2 (6) 4 (12) 5 (15) 2 (6)
9 (35) 0 (0) 1 (4) 0 (0) 4 (15)
108 ± 37 66 ± 18
107 ± 37 80 ± 26
CABG, coronary artery bypass grafting; ASD, atrial septal defect closure; PFO, patent foramen ovale closure; TAP, tricuspid annuloplasty; CPB, cardiopulmonary bypass; and AXC, aortic cross-clamp. Categorical data are presented as numbers of patients and percentage of sample; continuous data are presented as mean value ± SD.
Fig. 1. Echocardiographic imaging and evaluation of mitral valve geometrical parameters: (α1 and β1); the anterior and posterior mitral leaflet angles during the diastolic phase, (α2 and β2); the anterior and posterior mitral leaflet angles during the systolic phase, (1 to 2); the annular antero-posterior dimension. The broken white line shows the coaptation length.
diminished after the quadrangular resection. With regard to the mitral leaflet mobility, the leaflet remodeling technique strongly enhanced the posterior leaflet mobility, compared with the quadrangular resection. It is reasonable to conclude the quadrangular resection results in the potential for impaired posterior leaflet mobility. The nonresectional leaflet remodeling technique may have addressed this issue by preserving functionally favorable mobile leaflet tissue, thus enhancing the posterior leaflet excursion. The results also indicate that the leaflet remodeling tends to be more useful for improving mitral leaflet coaptation compared with the quadrangular resection, probably because the leaflet remodeling imbricated excessive prolapsed tissue into the LV without resection and generated a smooth leaflet coaptation surface [2,6]. Adams and colleagues reported coaptation length 5 mm should be documented to ensure adequacy of coaptation [9]. In the present results, the mean coaptation length was 8.7 mm in the leaflet remodeling group and 8.1 mm in the quadrangular resection group postoperatively, both of which favor the recommendation of mitral repair. In conclusion, the non-resectional leaflet remodeling eliminated MR, while significantly increasing mitral leaflet coaptation length. Compared to quadrangular resection, leaflet remodeling strongly enhanced posterior leaflet mobility.
Conflict of interest The authors report no relationships that could be construed as a conflict of interest.
18
Y. Shudo et al. / International Journal of Cardiology 186 (2015) 16–18
Fig. 2. Preoperative (Pre; solid bar) and postoperative (Post; cross-hatched bar) mitral valve geometric parameters in patients in the leaflet remodeling and quadrangular resection groups. * P b .05 between preoperative and postoperative values.
Fig. 3. Magnitude of changes in the mitral valve geometric parameters in patients in the leaflet remodeling and quadrangular resection (open bar) groups. * P b .05 between the leaflet remodeling group and quadrangular resection group.
References [1] J.C. Davila, R.P. Glover, R.G. Trout, et al., Circumferential suture of the mitral ring; a method for the surgical correction of mitral insufficiency, J. Thorac. Surg. 30 (1955) 531–563. [2] J.W. Macarthur Jr., J.E. Cohen, A.B. Goldstone, et al., Nonresectional single-suture leaflet remodeling for degenerative mitral regurgitation facilitates minimally invasive mitral valve repair, Ann. Thorac. Surg. 96 (2013) 1603–1606. [3] M. Enriquez-Sarano, J.F. Avierinos, D. Messika-Zeitoun, et al., Quantitative determinants of the outcome of asymptomatic mitral regurgitation, N. Engl. J. Med. 352 (2005) 875–883. [4] A. Carpentier, J. Relland, A. Deloche, et al., Conservative management of the prolapsed mitral valve, Ann. Thorac. Surg. 26 (1978) 294–302.
[5] H. Kasegawa, T. Shimokawa, T. Horai, et al., Long-term echocardiography results of mitral valve repair for mitral valve prolapse, J. Heart Valve Dis. 17 (2008) 162–167. [6] Y.J. Woo, J.W. Macarthur Jr., Posterior ventricular anchoring neochordal repair of degenerative mitral regurgitation efficiently remodels and repositions posterior leaflet prolapse, Eur. J. Cardiothorac. Surg. 44 (2013) 485–489. [7] Y. Shudo, H. Matsue, K. Toda, et al., A simplified echocardiographic measurements of direct effects of restrictive annuloplasty on mitral valve geometry, Echocardiography 27 (2010) 931–936. [8] K.R. Khabbaz, F. Mahmood, O. Shakil, et al., Dynamic 3-dimensional echocardiographic assessment of mitral annular geometry in patients with functional mitral regurgitation, Ann. Thorac. Surg. 95 (2013) 105–110. [9] D.H. Adams, A.C. Anyanwu, L. Sugeng, R.M. Lang, Degenerative mitral valve regurgitation: surgical echocardiography, Curr. Cardiol. Rep. 10 (2008) 226–232.
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Non-resectional leaflet remodeling mitral valve repair preserves leaflet mobility: A quantitative echocardiographic analysis of mitral valve configuration☆ Yasuhiro Shudo a, Jeffrey E. Cohen a,b, John W. MacArthur a,b, Andrew B. Goldstone a,b, Arudo Hiraoka b, Jessica Howard b, Alexander S. Fairman b, Jay Patel a, Bryan B. Edwards a, Pavan Atluri b, Y. Joseph Woo a,⁎ a b
Department of Cardiothoracic Surgery, Stanford University School of Medicine, United States Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania School of Medicine, United States
a r t i c l e
i n f o
Article history: Received 23 February 2015 Accepted 17 March 2015 Available online 18 March 2015 Keywords: Mitral regurgitation Mitral valve repair Echocardiography
Several studies have shown the mitral repair technique to be effective and safe for mitral regurgitation (MR) [1–5]. The classic quadrangular resection has become a highly reproducible approach with great long-term durability for treating MR [5]. Evolving from the classic repair, we have described a non-resectional leaflet remodeling mitral valve repair technique, in which the prolapsed leaflet tissue is inverted into the left ventricle (LV) to eliminate prolapse while maximizing leaflet surface for coaptation and preserving leaflet mobility [2,6]. This technique avoids the potential negatives of leaflet resection and neochords. Interestingly, post-repair mitral leaflet and annular geometry have yet to be fully quantified. Trans-esophageal echocardiography (TEE) [7,8] effectively assesses mitral valve geometry in the setting of different forms of mitral valve pathology and complex valve disease. In the present study, we evaluated the configuration of the mitral valve before and after mitral valve repair utilizing TEE. Between October 2010 and October 2012, 81 mitral valve operations performed at the University of Pennsylvania Health System were reviewed. This study was approved by the Institutional Review Board of the University of Pennsylvania IRB (Protocol number: 810968). The study population was limited to 59 patients who underwent TEE before
☆ Presented at the Southern Thoracic Surgical Association 60th Annual Meeting, Scottsdale, AZ, October 30–November 2, 2013. ⁎ Corresponding author at: 300 Pasteur Drive, Falk Cardiovascular Research Center, Stanford University School of Medicine, Stanford, CA 94305, United States. E-mail address: [email protected] (Y.J. Woo).
http://dx.doi.org/10.1016/j.ijcard.2015.03.239 0167-5273/© 2015 Elsevier Ireland Ltd. All rights reserved.
and after the operation. Of those, 33 patients underwent the nonresectional leaflet remodeling and 26 underwent the standard quadrangular resection with reapproximation for degenerative MR. The patients' baseline characteristics are presented in Table 1. In the leaflet remodeling group, the prolapsed portions were P2 (n = 23); P2/P3 (n = 4); P1/P2 (n = 4); P3 (n = 2). Briefly, the prolapsed segment is retracted into the atrium to reveal the LV endocardium, and a CV5 Gore-Tex suture is passed into the myocardium. The leading edge is inverted into LV, imbricating a portion of the leaflet and generating two near-apposing tissue folds emanating radially. These folds are sutured together with the Gore-Tex suture, thereby fixating the prolapsed leaflet tissue into the ventricular side and generating a smooth coaptation surface in the correct plane. In the quadrangular resection group, mitral valve repair is performed using the standardized technique. All patients tolerated the operation well. Intra-operative data are presented in Table 2. The comprehensive TEE examination was performed using the X4 matrix array transducer (iE33, Philips Medical Systems) in all 59 patients. Intra-operative TEE was conducted before sternotomy and after termination of cardiopulmonary bypass. All patients were with grade 3 or greater MR. Postoperatively, all patients showed MR equal to or less than grade 1, and the severity score decreased significantly, from 3.5 ± 0.7 to 0.2 ± 0.4 after leaflet remodeling, and from 3.5 ± 0.7 to 0.3 ± 0.6 after quadrangular resection. A four-chamber view was utilized for data acquisition. The imaging plane cuts the coaptation line perpendicularly, transecting P2 and A2. The measured variables were the annular antero-posterior dimension and coaptation length at midsystole. The annular antero-posterior dimension was measured as the distance between the center of the anterior and posterior mitral annulus at mid-systole. The coaptation length was obtained by tracing the coapted leaflets between the coaptation point of both leaflets and the tip of leaflet at mid-systole. Coaptation length index was defined as the ratio of the coaptation length to the annular anterior–posterior dimension [7]. The anterior and posterior mitral leaflet excursions were calculated using the following formula; α2 − α1 and β2 − β1 (Fig. 1). The annular antero-posterior dimension was significantly decreased in both groups. The coaptation length and coaptation length index were significantly increased in both groups. The anterior leaflet excursion remained unchanged in both groups. The posterior leaflet
Y. Shudo et al. / International Journal of Cardiology 186 (2015) 16–18
17
Table 1 Patient characteristics. Variables
Females, n (%) Age, y LVEF (%) Hypertension, n (%) Diabetes mellitus, n (%) Hyperlipidemia, n (%) Cerebrovascular disease, n (%) Atrial fibrillation/flutter, n (%) Smoking history, n (%)
Leaflet remodeling
Quadrangular resection
(n = 33)
(n = 26)
21 (64) 62 ± 10 59 ± 12 15 (45) 1 (3) 13 (39) 1 (3) 6 (18) 17 (52)
15 (58) 66 ± 14 55 ± 14 9 (35) 2 (8) 4 (15) 0 (0) 12 (46) 5 (19)
Data are presented as mean value ± SD or no. of patients (%).
excursion was preserved in the leaflet remodeling group, while it was greatly diminished in the quadrangular resection group (Fig. 2). In the between-group comparisons, the average change in the coaptation length tended to be larger in the leaflet remodeling group. Moreover, the average change in the posterior leaflet excursion was greater in the quadrangular resection group than in the leaflet remodeling group. This trend probably stems from the different surgical approaches, and suggests the leaflet remodeling may be beneficial in some cases (Fig. 3). Statistical calculations were performed using the JMP 9.0 (SAS Institute Inc.). Continuous variables are expressed as the mean ± SD. Comparisons were made using the Wilcoxon–Mann–Whitney U test. Categorical variables were compared by chi square test and the Fisher exact test. A P-value less than .05 was considered to be statistically significant. This study demonstrated the quantitative echocardiographic analysis of mitral valve configuration following either leaflet remodeling or quadrangular resection. The detailed quantitative analysis showed a significant decrease in the annular antero-posterior dimension and a remarkable increase in the leaflet coaptation length in both study groups, with the increase in coaptation length tending to be larger in the leaflet remodeling group. The data clearly illustrate the preservation of the anterior leaflet excursion following either leaflet remodeling or quadrangular resection. Importantly, however, the posterior leaflet excursion was preserved after leaflet remodeling, while it was greatly
Table 2 Surgical data. Variables
Leaflet remodeling
Quadrangular resection
(n = 33)
(n = 26)
Non-resectional leaflet remodeling, n (%) Quadrangular resection with reapproximation, n (%) Annuloplasty ring size used Minimally invasive approach, n (%) Concomitant procedures CABG, n (%) ASD, n (%) PFO, n (%) TAP, n (%) Maze, n (%) Intraoperative data CPB time, min AXC time, min
33 (100) 0 (0) 31 ± 3 24 (73)
0 (0) 26 (100) 32 ± 4 0 (0)
1 (3) 2 (6) 4 (12) 5 (15) 2 (6)
9 (35) 0 (0) 1 (4) 0 (0) 4 (15)
108 ± 37 66 ± 18
107 ± 37 80 ± 26
CABG, coronary artery bypass grafting; ASD, atrial septal defect closure; PFO, patent foramen ovale closure; TAP, tricuspid annuloplasty; CPB, cardiopulmonary bypass; and AXC, aortic cross-clamp. Categorical data are presented as numbers of patients and percentage of sample; continuous data are presented as mean value ± SD.
Fig. 1. Echocardiographic imaging and evaluation of mitral valve geometrical parameters: (α1 and β1); the anterior and posterior mitral leaflet angles during the diastolic phase, (α2 and β2); the anterior and posterior mitral leaflet angles during the systolic phase, (1 to 2); the annular antero-posterior dimension. The broken white line shows the coaptation length.
diminished after the quadrangular resection. With regard to the mitral leaflet mobility, the leaflet remodeling technique strongly enhanced the posterior leaflet mobility, compared with the quadrangular resection. It is reasonable to conclude the quadrangular resection results in the potential for impaired posterior leaflet mobility. The nonresectional leaflet remodeling technique may have addressed this issue by preserving functionally favorable mobile leaflet tissue, thus enhancing the posterior leaflet excursion. The results also indicate that the leaflet remodeling tends to be more useful for improving mitral leaflet coaptation compared with the quadrangular resection, probably because the leaflet remodeling imbricated excessive prolapsed tissue into the LV without resection and generated a smooth leaflet coaptation surface [2,6]. Adams and colleagues reported coaptation length 5 mm should be documented to ensure adequacy of coaptation [9]. In the present results, the mean coaptation length was 8.7 mm in the leaflet remodeling group and 8.1 mm in the quadrangular resection group postoperatively, both of which favor the recommendation of mitral repair. In conclusion, the non-resectional leaflet remodeling eliminated MR, while significantly increasing mitral leaflet coaptation length. Compared to quadrangular resection, leaflet remodeling strongly enhanced posterior leaflet mobility.
Conflict of interest The authors report no relationships that could be construed as a conflict of interest.
18
Y. Shudo et al. / International Journal of Cardiology 186 (2015) 16–18
Fig. 2. Preoperative (Pre; solid bar) and postoperative (Post; cross-hatched bar) mitral valve geometric parameters in patients in the leaflet remodeling and quadrangular resection groups. * P b .05 between preoperative and postoperative values.
Fig. 3. Magnitude of changes in the mitral valve geometric parameters in patients in the leaflet remodeling and quadrangular resection (open bar) groups. * P b .05 between the leaflet remodeling group and quadrangular resection group.
References [1] J.C. Davila, R.P. Glover, R.G. Trout, et al., Circumferential suture of the mitral ring; a method for the surgical correction of mitral insufficiency, J. Thorac. Surg. 30 (1955) 531–563. [2] J.W. Macarthur Jr., J.E. Cohen, A.B. Goldstone, et al., Nonresectional single-suture leaflet remodeling for degenerative mitral regurgitation facilitates minimally invasive mitral valve repair, Ann. Thorac. Surg. 96 (2013) 1603–1606. [3] M. Enriquez-Sarano, J.F. Avierinos, D. Messika-Zeitoun, et al., Quantitative determinants of the outcome of asymptomatic mitral regurgitation, N. Engl. J. Med. 352 (2005) 875–883. [4] A. Carpentier, J. Relland, A. Deloche, et al., Conservative management of the prolapsed mitral valve, Ann. Thorac. Surg. 26 (1978) 294–302.
[5] H. Kasegawa, T. Shimokawa, T. Horai, et al., Long-term echocardiography results of mitral valve repair for mitral valve prolapse, J. Heart Valve Dis. 17 (2008) 162–167. [6] Y.J. Woo, J.W. Macarthur Jr., Posterior ventricular anchoring neochordal repair of degenerative mitral regurgitation efficiently remodels and repositions posterior leaflet prolapse, Eur. J. Cardiothorac. Surg. 44 (2013) 485–489. [7] Y. Shudo, H. Matsue, K. Toda, et al., A simplified echocardiographic measurements of direct effects of restrictive annuloplasty on mitral valve geometry, Echocardiography 27 (2010) 931–936. [8] K.R. Khabbaz, F. Mahmood, O. Shakil, et al., Dynamic 3-dimensional echocardiographic assessment of mitral annular geometry in patients with functional mitral regurgitation, Ann. Thorac. Surg. 95 (2013) 105–110. [9] D.H. Adams, A.C. Anyanwu, L. Sugeng, R.M. Lang, Degenerative mitral valve regurgitation: surgical echocardiography, Curr. Cardiol. Rep. 10 (2008) 226–232.
