PREOPERATIVE DIAGNOSIS: Mitral Regurgitation

OPERATION: Complex Mitral Valve Repair (Anterior Leaflet and Posterior Commissural Prolapse; Gore-Tex Chords x 3: 2 to A2, 1 to the Posterior Commissure; Magic Sutures x 2 to Posterior Commissure; True Size 28mm Physio II Ring)

CO-SURGEONS: David Adams, MD and Joanna Chikwe, MD

INDICATIONS FOR SURGERY: The patient is a 34-year-old male who presented with severe mitral valve regurgitation. The patient is now referred for elective intervention.

OPERATIVE PROCEDURE: We now explored the mitral valve. There was posterior commissural prolapse as well as a prolapse of A2 all due to chordal elongation. We first placed sutures around the annulus. We then used three Gore-Tex chords to correct the prolapse of the anterior leaflet and commissure. We did perform two Magic sutures in the posterior commissure and then used a single Gore-Tex chord to correct commissural prolapse and then added two chords, one to A3 and one to A2 to correct residual anterior leaflet prolapse. A size 28mm Physio II ring was implanted. 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 34-year-old man with severe mitral valve regurgitation on the basis of posterior commissural prolapse, which is highlighted in red on this QLAB analysis from 3D transesophageal echocardiography. This can be a complex lesion, and it is important to use a non-resection technique in those circumstances. We begin by placing the annular sutures to help us expose the commissure, and the commissure is the area where the two leaflets come together and hinge, and you can see that when I fill the ventricle with saline this area of the valve leaks, so we are marking the commissural area with ink and this will give us a sight line as we try and correct this prolapse. We are first going to place what Carpentier calls a magic suture which is an everting suture of Prolene to roll the edges of the commissure together near the annulus. Usually we place two of these. These will not overly narrow a valve this size. And the next step then in a non-resection technique would be chordal transposition or in this case chordal replacement. You can see we are lifting up the papillary muscle and placing a few of these Gore-Tex sutures into the fibrous tip. Now to correct the commissural prolapse, I will pass one edge through the anterior leaflet and one edge through the posterior leaflet. This patient has an additional middle anterior leaflet prolapse which we will correct with the second chord. We typically will place our ring first and then adjust the height of the chords when we will fill the ventricle with saline. This is a functional adjustment of the height of these chords as opposed to the geometric adjustment where we pick up a predetermined size and implant them in the free edge. You can see we are filling the ventricle with saline as we confirm the height of the individual chords. We are adding an additional chord in the A2 segment here and then we can correct the height with the ventricle full and you can see we have a perfect closure line and a competent valve and what is a very complex lesion of commissural or anterior leaflet prolapse with an excellent echo.