This video shows a complex mitral valve repair using a modification of the Leipzig loop technique (1) with a modular Gore-Tex neochord system to address the anterior and the posterior leaflet.
The patient was a 70-year-old man with a history of acute bacterial endocarditis treated with intravenous antibiotics. His echocardiogram showed bileaflet prolapse with a complex jet, and 3D echocardiography confirmed lateral P2 and A2 prolapse.
The surgical approach was a right minithoracotomy in the fourth intercostal space and cardioplegic arrest of the heart using del Nido cardioplegia.
The heart was opened through Sundergaard’s groove, and the valve was exposed. The authors appreciated a fused A1-P1 and a healed vegetation in the P2 segment laterally. This vegetation was resected in a triangular fashion. With plans of performing a sliding pasty of P2 laterally, they proceeded to perform an incision at the base of P2. The sliding pasty was performed using CV6 Gore-Tex suture to close the P2 segment to the annulus in a running fashion. A second stitch was started at the free edge of the leaflets, attaching effectively P2 to the most medial portion of P1. This was performed in a running fashion using CV6 Gore-Tex, and the sutures were tied at the base of the leaflet.
A saline test demonstrated residual lateral A2 and P2 prolapse. The authors used a modified adjustable chord system using a “mini loop” created to be anchored in the anterolateral papillary muscle. The loop was made of CV5 Gore-Tex and was anchored with a pledgeted mattress stitch. The exposure was obtained using a nitinol flexible retractor. One by one, CV5 Gore-Tex sutures were passed through the “mini loop” to secure them and to be used as neochords. A total of five of these sutures were used in this case. The sutures were anchored to the A1 segment using a figure-of-eight locking stitch (2). Each of the arms of the neochords were secured in the same fashion, separated 1 mm apart (for the arms corresponding to the same sutures). Two of the neochords were secured to the medal A1 and the lateral aspect of A2. The other three neochords were applied to the P2 segment, one bridging the area of the reconstructed P2 while the other two were more medial. It is important to maintain the leaflets in a flail or prolapsed position so as to then adjust the leaflets downwards, which is easier than adjusting them toward the atrium.
All the neochords were applied but not tied and the valve was tested, still showing A2 and P2 prolapse. The valve was adjusted by grabbing one of the neochords and pushing down the posterior leaflet to the appropriate height, and the valve was retested with resulting improvement of the prolapse. Selective annuloplasty ring stitches were applied to expose the valve further. A retest showed a good coaptation zone. The anterior chords were adjusted for height, and satisfied with this the valve was retested. This time the authors saw a good coaptation zone and no runoff of the ink testing. The P2 segment was readjusted by holding one of the sutures and pushing down on the leaflet. Satisfied with this, the authors proceeded to tie all the neochords. Each of the sister arms were tied to each other with at least 12 knots. The valve was retested, and there was a residual leak laterally. The ring was sized to a 38 mm Carpentier-Edwards Physio II ring, which was applied using Cor-Knot®. The residual leak in the lateral commissure was fixed by applying a simple CV5 stitch as a commissuroplasty. The valve was retested, and no residual leak was identified. An ink test showed no runoff of the ink.
The left atrium was closed, and the postoperative echocardiogram showed no residual mitral regurgitation with a mean gradient of 3 mm Hg. The patient did well postoperatively, and he was discharged home on postoperative day number four.
References
- von Oppell UO, Mohr FW. Chordal replacement for both minimally invasive and conventional mitral valve surgery using premeasured Gore-Tex loops. Ann Thorac Surg. 2000;70(6):2166-2168.
- El Gabry M, Jakob H, Lubarski J, Mourad F, Shehada S-E. Minimally invasive video-assisted mitral valve repair using PTFE-chordae: a simplified technique. August 2018. doi:10.25373/ctsnet.6990317.
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1 Comment
This was a really nice case and very enjoyable to watch! The case demonstrates that rib spreading is generally required for such mini-thoracotomy cases which can increase pain even relative to that of a sternotomy. Perhaps this obviously talented team should consider robotics in the future to avoid the need for such a large incision with rib spreading. The idea of using a single loop set down on a papillary muscle to anchor multiple neochords, while not novel, is very nicely demonstrated here. Although not an issue in this case, one thing to avoid would be crossing vertical midline with a neochord to the other side of the valve as this can cause restriction and pleating. Great case and excellent result.