PREOPERATIVE DIAGNOSIS: Mitral Regurgitation

OPERATION: Complex Mitral Valve Repair (Bileaflet Prolapse; Triangular Resection of P2; Gap Closure of P2, P3; True Size 32mm Physio II Ring; Gore-Tex Chord x 1 to Correct A2 Prolapse due to Chordal Elongation)

SURGEON: David Adams, MD

INDICATIONS FOR SURGERY: The patient is a 55-year-old gentleman with a 5-year history of mitral valve prolapse with severe mitral valve regurgitation referred for elective intervention.

OPERATIVE PROCEDURE: The mitral valve was exposed through Sondergaard's groove. There were two ruptured chords to a tall P2 segment. A triangular resection was performed. The gap was closed between P2 and P3. After reconstruction of the leaflet, a true-size 32mm Physio II ring was implanted. The valve continued to have an abnormal saline test because of the anterior leaflet prolapse due to chordal elongation. This was identified preoperatively on the Q lab analysis with the real-time 3-D TEE. I used a Gore-Tex chord to correct this. The valve had a good line of symmetry and a normal saline test.

POSTOPERATIVE ANALYSIS: The post-bypass transesophageal echo revealed absent residual regurgitation.

Video Transcript:

I am Dr. David Adams, the Chairman of Heart Surgery at Mount Sinai Medical Center. Today, I would like to show you a video of mitral valve repair utilizing the new Carpentier-Edwards Physio II ring of which I am a co-inventor.

This patient is a 55-year-old man with preserved ventricular function and 4+ mitral valve regurgitation on the basis of posterior leaflet prolapse, which you can see is colored in red on this 3D echo picture. Valve analysis reveals the ruptured chord in the tall posterior leaflet middle segment, and the adjacent segment is of normal height. We begin this operation by marking chords that we can preserve on either side of this ruptured chord, and in this case we are going to perform a limited triangular resection of the prolapsing segment. We limit the resection here because of the normal height and length of adjacent chords. Here we will close this with interrupted Prolene, and we are very careful to do this so that we have a symmetric closure. Often times these leaflets have a discrepant height so it is important we make that up along the length of our closure and that is why we prefer interrupted sutures. Now we are filling the ventricle with saline and our next step is to pass a Gore-Tex chord into the papillary muscle, and we will use that later to reinforce our closure if we have a residual prolapse. Now we are using a sizer for the new Physio II ring; in this case we have implanted a size-32 ring and now we are filing the ventricle with saline and you can see this posterior leaflet as one source of residual regurgitation and that is the separation of the indentation between the middle scallop and lateral scallops. We are closing that with an additional few Prolene sutures. Now we are using the Gore-Tex chord that we placed before ring implantation to adjust the height of the anterior leaflet and correct this tendency for anterior leaflet prolapse, and now we can fill the ventricle with saline and we have a very symmetric, well-positioned closure line between the two leaflets. Once we have confirmed the correct height of the Gore-Tex chord we add additional knots to secure it. Then we fill the ventricle with saline; we can mark our closure line with ink which allows us to asses the level and depth of coaptation which is quite excellent.