Anterior Leaflet Repair With Patch Augmentation for Mitral Regurgitation

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Anterior Leaflet Repair With Patch Augmentation for Mitral Regurgitation
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  Anterior Leaflet Repair With Patch Augmentationfor Mitral Regurgitation Matthew A. Romano,  MD,  Himanshu J. Patel,  MD,  Francis D. Pagani,  MD, PhD, Righard L. Prager,  MD,  G. Michael Deeb,  MD,  and Steven F. Bolling,  MD Section of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan Background.  Anterior leaflet repair continues to posesignificant operative challenges, particularly in patientswith retracted or “short” anterior leaflets, due to rheu-matic or radiation induced mitral valve disease. Thisoften results in abandonment of repair in favor of mitralvalve replacement, requiring anticoagulation and alter-ing left ventricular (LV) function and geometry. Thisstudy examines our experience of anterior leaflet repairwith patch augmentation.  Methods.  Forty-two patients underwent mitral valverepair for a shortened anterior leaflet from 1994 to 2003.Twenty-two patients with a mean age of 53  6 years hadradiation valvulitis (XR) whereas 20 patients, age 28  7years had rheumatic heart disease (RHD). Those patientswith XR had a mean New York Heart Association(NYHA) class of 3.2  0.4 and an angina score of 2.1  0.6compared with a NYHA class 3.8  0.2 and no angina inRHD patients. All patients presented with severe MR.Anterior leaflet augmentation with a gluteraldehyde-treated, autologous pericardial patch and complete annu-loplasty ring was used in all patients. Additionally,extensive subvalvar debridement was performed in RHDpatients. Twelve XR patients underwent concomitantCABG with a mean of 2.4  0.8 grafts/patient. Additionalsurgical procedures included tricuspid valve repair, an-terior septal defect, and aortic valve replacement. Meanfollow-up was 39  10 months for XR patients and 12  25 months for RHD patients. Results.  There were two late deaths in XR patientsfrom underlying malignancies and no deaths in RHDpatients. Two RHD patients required reoperation forrecurrent mitral regurgitation at 3 and 20 months. Allpatients demonstrated clinical improvements (NYHAI-II) following repair. No mitral stenosis was induced. Conclusions.  Despite anterior leaflet shortening from XRor rheumatic alterations, opportunity still exists for gratify-ing mitral valve repair. By utilizing anterior leaflet patchaugmentation, concomitantly with ring annuloplasty, anti-coagulation is avoided, LV geometry is preserved, andfollow-up reveals excellent functional improvement.(Ann Thorac Surg 2005;79:1500–4)© 2005 by The Society of Thoracic Surgeons M itral valve dysfunction is a well-known complica-tion in long-term survivors of mediastinal irradi-ation [1–3]. The postradiation leaflet changes include fibrosis, thickening, and shortening with or without cal-cification [4, 5]. Similar alterations may also be seen in rheumatic heart disease (RHD), due to the chronic fibro-sis and scarring. Consequently, these changes, althoughfrom different modalities, may result in a short,“shrunken” anterior leaflet. This short anterior leafletdoes not provide for adequate coaptation and results inmitral regurgitation and the subsequent development of heart failure. Historically, mitral valve replacement hasbeen used to surgically manage these patients. Today thebenefits of mitral valve (MV) reconstruction for operativecorrection of mitral regurgitation (MR) are well estab-lished. These benefits include low perioperative mortal-ity, preservation of left ventricular function, avoidance of long-term anticoagulation therapy, decreased thrombo-embolic complications, a low risk of native valve endo-carditis, excellent long-term freedom from reoperation,and improved survival as compared to patients undergo-ing valvular replacement. However, those patients withradiation or rheumatic changes, who have a fibrotic andretracted anterior leaflet, pose significant operative chal-lenges. Frequently, in this situation due to technicalproblems and concerns of long-term results, repair hasbeen abandoned in favor of replacement. In this study wedescribe our experience of anterior leaflet repair withpatch augmentation to surgically manage shortened mi-tral valve anterior leaflets in patients with radiationvalvular disease and RHD. Patients and Methods The records of 42 consecutive patients who underwentmitral valve repair for a shortened anterior leaflet from1994 to 2003 were reviewed. Twenty-two patients hadradiation valvulitis (XR) from previous mediastinal irra-diation treatment for a neoplasm. The primary neo-plasms requiring radiation were breast cancer, lym-phoma, and germ cell tumors (Table 1). The remaining 20 Accepted for publication Aug 23, 2004.Presented at the Fiftieth Annual Meeting of the Southern ThoracicSurgical Association, Bonita Springs, FL, Nov 13–15, 2003.Address reprint requests to Dr Bolling, 2120 Taubman Center, Box 0348,1500 E. Medical Center Dr., Ann Arbor, MI 48109–0348; e-mail:sbolling@umich.edu. © 2005 by The Society of Thoracic Surgeons 0003-4975/05/$30.00Published by Elsevier Inc doi:10.1016/j.athoracsur.2004.08.086  C A R D I   O V A S  C U L  A R  patients had RHD. For this study the operative reports,clinical histories, echocardiograms, electrocardiograms,and cardiac catheterization data were reviewed. Fol-low-up data were obtained from current clinical records,reports from primary physicians, and laboratory data(electrocardiograms and echocardiograms).The preoperative demographic data of patients in thisstudy are listed in Table 2. The mean age of the XR was 53  6 years, and 28  7 years in the RHD patients. Themean New York Heart Association (NYHA) functionalclass for XR and RHD patients was 3.2  0.4 and 3.8  0.2,respectively. The XR cohort had an angina score of 2.1  6 while there was no angina in rheumatic patients. Allpatients presented with severe mitral regurgitation.The indications for mediastinal radiation therapy werebreast cancer (n  11), lymphoma (n  8), and seminoma(n    3). The most recent increase has been seen inpatients surviving treatment for Hodgkin’s disease, andthis is expected to continue to increase. The mean inter-val between irradiation and valvular heart operation was17  12 years.The concept of this repair with anterior patch augmen-tation is to lengthen the severely shortened and retractedanterior leaflet to reestablish coaptation (Fig 1). Theoperative procedure was done by sternotomy. An autol-ogous piece of pericardium was harvested immediatelyafter median sternotomy and bathed in 3% gluteralde-hyde for 7 minutes. Following patch harvest, patientswere placed on standard cardiopulmonary bypass withbicaval cannulation. Standard blood cardioplegic arrestwas initiated with antegrade flow in all patients. Retro-grade cardioplegia was used as indicated. A standardright-sided left atriotomy was made parallel to the inter-atrial groove and extended and wrapping inferiorly andsuperiorly in the direction of the left superior and inferiorpulmonary veins, to facilitate exposure. A self-retainingretractor was placed. The valve was inspected and acurvilinear incision was made in the anterior leafletparallel to the anterior annulus, from trigone to trigone,leaving 1 to 2 mm of leaflet tissue. This caused theanterior leaflet to “fall” forward and into the ventricle.The autologous patch was then generously fashioned tothe size of the ring that was selected to restore the zoneof coaptation between the anterior and posterior leaflets.Specifically, the width of the patch was cut to be at leastas wide as the trigone to trigone distance. Once appro-priately sized, the patch was sewn into the deficit of theanterior leaflet with two running 4-0 or 5-0 Prolenesutures (Fig 2). A complete annuloplasty ring was used in all patients. The annuloplasty ring size was determinedby the trigone to trigone distance as well. Extensivesubvalvar debridement was performed in RHD patients.The completed repair restored the intraventricular zoneof coaptation (Fig 3). This was confirmed at the time of  repair by filling the LV with saline through a bulb syringeand visually inspecting the leaflets. Additionally, trans-esophageal echocardiography was also used to assesscoaptation.Concomitant procedures were common. Twelve of theXR patients underwent simultaneous coronary arterybypass grafting with a mean of 2.4    0.8 grafts/patient.Tricuspid valve repair was performed in 2 of the radia-tion valvulitis patients and 3 of the rheumatic heartdisease patients. Aortic valve replacement occurred in 5XR patients. Atrial septal defect repair was performed in2 of the XR patients and 3 of the RHD patients (Table 3). Table 1. Primary Neoplasms of Patients Who Underwent  Mediastinal Radiation Primary Neoplasm NumberBreast cancer 11Lymphoma 8Germ cell tumor 3 Table 2. Preoperative Patient Demographics XR RHDNumber 22 20Male 10 9Female 12 11Age 53  6 28  7NYHA class 3.2  0.6 3.8  0.2 NYHA    New York Heart Association; RHD    rheumatic heartdisease; XR  radiation valvulitis.  Fig 1. The retracted and shortened anterior leaflet with loss of coap-tation is incised and augmented or lengthened with a pericardial patch to restore the zone of coaptation. After incision at point   A  , the pericardial patch extends from point   A  to  A1  , thereby lengthening the anterior leaflet. 1501 Ann Thorac Surg ROMANO ET AL2005;79:1500–4 ANTERIOR LEAFLET REPAIR FOR MR      C     A     R     D     I     O     V     A     S     C     U     L     A     R  Results The mean follow-up time was 39  10 months (range 12to 67 months) for XR patients and 12  25 months (range4 to 56 months) for RHD. Follow-up was complete in bothgroups.Two of the RHD patients required reoperation. Mitralvalve replacement was performed in both patients forrecurrent mitral regurgitation. This occurred at and 3 and20 months postpatch augmentation. The overall survivalwas 95%. There were 2 late deaths in the XR patients at 27and 48 months. Death was due to the underlying diseasein both patients. There were no deaths in the RHDpatients. Clinical improvements were noted in all pa-tients. The NYHA class improved to class I or II. Fol-low-up echocardiography did demonstrate stiffening of the patch; however, mitral stenosis was not created inany patient. Patients were anticoagulated for 30 daysfollowing repair. Comment The extensive fibrotic changes that occur in the anteriorleaflet of the mitral valve following radiation to the medi-astium continue to pose significant surgical challenges.These morphologic changes can also be seen in rheumaticalterations. Historically, these patients have been treatedwithmitralvalvereplacement.Fewreportsexistonanteriorleaflet patch repair. In this study we demonstrate that thesepatients are amenable to repair with anterior patch aug-mentation. This technique utilizes autologous gluteralde-hyde-treatedpericardiumcombinedwithringannuloplastyand subvalvar debridement to repair the mitral valve. Thisavoids the necessity of chronic anticoagulation and itsassociated sequela when a mechanical valve is inserted.Furthermore,mitralvalvereplacementisknowntoalterthegeometry of the left ventricle [6, 7]. Mitral valve repair preserves the mitral valve apparatus and this has beenshown to enhance and maintain left ventricular function[8–10].Thisdataindicatesthatmitralvalverepairshouldbeentertained, perhaps even when anticoagulation cannot beavoided. In our series, five XR patients underwent concom-itant mechanical aortic valve replacement, thereby necessi-tating long-term anticoagulation. However, by repairingthe mitral valve, the disruption of the mitral valve-leftventricular unit is not altered and heart function may bepreserved.  Fig 3. In the completed repair, the intraventricular restoration of the zone of coaptation is accomplished. The pericardial patch may bil-low into the left atrium; however, coaptation is maintained. Table 3. Concomitant Operative Procedures XR RHDCABG 12 0Grafts/pt 2.4  0.8 n/aTVR 2 3AVR 5 0ASD 2 3 ASD    atrial septal defect; AVR    aortic valve replacement;CABG    coronary artery bypass graft; RHD    rheumatic heartdisease; XR  radiation valvulitis.  Fig 2. As seen from the surgeon’s view, a curvilinear incision ismade in the anterior leaflet, parallel to the anterior annulus, leaving 1 to 2 mm of anterior leaflet tissue (top). This causes the anterior leaflet to “fall” or drop forward and into the ventricle (middle). Thesutures for ring annuloplasty are then placed. Following adequatesizing, the pericardial patch is sewn into the anterior leaflet deficit (bottom). In the completed repair the pericardial patch assumes themajority of the area of the anterior leaflet and coaptation with the posterior leaflet is obtained. 1502  ROMANO ET AL Ann Thorac SurgANTERIOR LEAFLET REPAIR FOR MR 2005;79:1500–4  C A R D I   O V A S  C U L  A R  The cause of late death in our series in the irradiatedpatients was related to the underlying disease, and notthe return of mitral regurgitation and congestive heartfailure. The overall survival in this study was 95%. Theactuarial survival in patients with patch augmentation forXR is 90% (20 of 22), which is slightly better than the 82%reported by another series of valvular heart operation inpatients who underwent mediastinal radiation [11]. Pre- vious studies have indicated that in addition to malig-nancy, heart failure is a significant cause of late death.NYHA functional class IV symptoms, atrial fibrillation,congestive heart failure, and poor left ventricular func-tion have been identified as preoperative factors for latecardiac death [11]. In our series the mean preoperative NYHA class was III and no patient had atrial fibrillation.In the presence of atrial fibrillation one may consideradditional surgical intervention. It is the policy at ourinstitution to perform a MAZE procedure in patients withatrial fibrillation while undergoing valve repair or re-placement. Our approach to surgically treat these pa-tients before the development of severe symptoms andleft ventricular dysfunction may have a role in the favor-able results. Many surgical series in this group of radi-ated patients have been somewhat disappointing, due torecurrent mitral regurgitation from continued tissue andleaflet shortening and retraction after repair. We did seestiffening of the patch with follow-up echocardiography.However, this approach of effectively lengthening theanterior leaflet with an overly generous patch that allowfor continued retraction of the native tissue is appealing.For this reason we are not concerned with the billowingof the leaflets often seen with the oversized patch. Ulti-mately, mitral valve repair with anterior leaflet patchaugmentation does not reverse radiation changes. Butthis technique avoids the need for anticoagulation andsustains left ventricular function. Ultimately this maydelay the onset of heart failure as it relates to mitral valvedisease and improve quality of life. Although there hasbeen question of the durability of valvular repair withradiated tissue [11] , none of the patients in our series required revision to a mechanical valve at over 3 years of follow-up. Clearly, more long-term data are necessary toreach firm conclusions.The changes seen with radiation or rheumatic alter-ations are part of an anatomic disease spectrum that mayinclude degenerative changes and endocarditis. In thissetting undersizing the mitral annulus is not effective.This is in contradistinction to geometric disease in whichthere is dilatation of the left ventricle, and an undersizedannuloplasty ring would provide significant functionalbenefit. Therefore, in the series presented here withanatomic disease we did not undersize the ring, butrather sized the annuloplasty ring according to the dis-tance between the trigones.Regarding this technique of anterior patch extensionfrom rheumatic retraction of the anterior leaflet, extensivesubvalvar debridement was performed in RHD patientsenabling repair of the valve. It is important to highlight inthese RHD patients, when anterior leaflet patch augmenta-tion may not be indicated. Occasionally, RHD patients withall embracing thickened and fibrotic or even calcified sub-valvar apparatus would preclude repair. These patientsmay be better served by mechanical replacement. Also, inthe presence of shortened chordae from such advanceddisease we would advocate mitral valve replacement asopposed to chordal elongation or replacement. Such ma-neuvers would most likely not provide long-term durabil-ity. This may explain why 2 of the RHD patients developedrecurrenceofmitralregurgitationandrequiredreoperationand mitral valve replacement. These patients had an all-embracing calcified subvalvar apparatus and, although ex-tensive debridement was performed, these patients in ret-rospect should have been initially considered for mitralvalve replacement. Ultimately, the decision to replace themitral valve or debride the subvalvar apparatus must bedetermined by the comfort level of the operating surgeon.In this series, there was no patch augmentation of theposterior leaflet performed. This technique has beenused in RHD, but has not been specifically described forthe treatment of XR. In these stiff and shrunken ventriclesassociated with radiation one would be wary of thedevelopment of left ventricular outflow tract obstructionby systolic anterior motion (SAM) being pushed forwardby an overly large augmented posterior leaflet [12].Not surprisingly, concomitant operative procedureswere common. Coronary artery bypass grafts were per-formed in 54% of XR patients. Twenty-two percent of XRpatients underwent simultaneous aortic valve replace-ment. This demonstrates the extensive damage that me-diastinal radiation imparts on the heart. All of thesepatients demonstrated diastolic dysfunction and in-creased ventricular stiffness. However, the need for ad-ditional procedures was not associated with increasedmortality.It is known that both radiation-induced and rheumaticvalvular heart disease is a progressive and widespreadprocess [13] , that may ultimately lead to progressive deterioration of heart function. Further information andfollow-up is needed to determine the extended long-termdurability of patch augmentation of the anterior leaflet.However, these results demonstrate excellent utility of repair and this technique should be considered for thesepatients. References 1. Strender LE, Lindahl J, Larsson LE. Incidence of heartdisease and functional significance of changes in the elec-trocardiogram 10 years after radiotherapy for breast cancer.Cancer 1986;57:929–34.2. Lederman GS, Sheldon TA, Chaffey JT, Herman TS, GelmanRS, Coleman CN. Cardiac disease after mediastinal irradia-tion for seminoma. Cancer 1987;60:772–6.3. Hancock SL, Donaldson SS, Hoppe RT. Cardiac diseasefollowing treatment of Hodgkin’s disease in children andadolescents. J Clin Oncol 1993;11:1208–15.4. Brosius FC 3rd, Waller BF, Roberts WC. Radiation heartdisease. Analysis of 16 young (aged 15 to 33 years) necropsypatients who received over 3,500 rads to the heart. Am J Med1981;70:519–30. 1503 Ann Thorac Surg ROMANO ET AL2005;79:1500–4 ANTERIOR LEAFLET REPAIR FOR MR      C     A     R     D     I     O     V     A     S     C     U     L     A     R  5. Veinot JP, Edwards WD. Pathology of radiation-inducedheart disease: a surgical and autopsy study of 27 cases. HumPathol 1996;27:766–73.6. Schuler G, Peterson KL, Johnson A, et al. Temporal responseof left ventricular performance to mitral valve surgery.Circulation 1979;59:1218–31.7. Huikuri HV. Effect of mitral valve replacement on left ventric-ular function in mitral regurgitation. Br Heart J 1983;49:328–33.8. Goldman ME, Mora F, Guarino T, Fuster V, Mindich BP.Mitral valvuloplasty is superior to valve replacement forpreservation of left ventricular function: an intraoperativetwo-dimensional echocardiographic study. J Am Coll Car-diol 1987;10:568–75.9. Tischler MD, Cooper KA, Rowen M, LeWinter MM. Mitralvalve replacement versus mitral valve repair. A Doppler andquantitative stress echocardiographic study. Circulation1994;89:132–7.10. Bolling SF, Pagani FD, Deeb GM, Bach DS. Intermediate-term outcome of mitral reconstruction in cardiomyopathy. J Thorac Cardiovasc Surg 1998;115:381–8.11. Handa N, McGregor CG, Danielson GK, et al. Valvular heartoperation in patients with previous mediastinal radiationtherapy. Ann Thorac Surg 2001;71:1880–4.12. Mihaileanu S, Marino JP, Chauvaud S, et al. Left ventricularoutflow obstruction after mitral valve repair (Carpentier’stechnique). Proposed mechanisms of disease. Circulation1988;78(3 Pt 2):I78–84.13. Adams MJ, Hardenbergh PH, Constine LS, Lipshultz SE.Radiation-associated cardiovascular disease. Crit Rev OncolHematol 2003;45:55–75. DISCUSSION DR DANIEL L. MILLER  (Atlanta, GA): Dr Romano, in thepatients who underwent reoperation did any of the patientsundergo surgery for patch dehiscence and were there any signsof leakage related to the leaflets? DR ROMANO : No. The rheumatic patients had a very thick-ened and fibrotic subvalvular apparatus. I think it was thedevelopment of refibrosis or the continued progression of thefibrotic process that led to patch failure. In retrospect thesepatients may have been better served by mitral valve replace-ment. But, no, there were no patch blowouts. DR THORALF SUNDT  (Rochester, MN): They certainly are achallenging group of patients and we frequently wind upevaluating them for transplantation a few years after theirvalvular procedure. I was intrigued to see the size of your patch,because certainly one of my questions in reading your abstract iswhat happens to progressive fibrosis, and I assume the design isthat the patch is large enough such that even if the native valveshrivels up to nothing you will still have a functional valve?Did you mention, I apologize if I missed it, what was thedenominator, what fraction of the radiation patients underwenta reparative technique? I think it is a terrific paper and I ampleased you presented it here. DR ROMANO : Of the radiation patients? DR SUNDT : How many total radiation patients were evaluatedfor valvular surgery and therefore what percentage of the totalhad repair versus replacement? I might have missed that. DR ROMANO : A total of 32 patients with either radiation orvalvular disease were evaluated for possible repair. Ultimately22 patients underwent anterior leaflet repair with patchaugmentation. 1504  ROMANO ET AL Ann Thorac SurgANTERIOR LEAFLET REPAIR FOR MR 2005;79:1500–4  C A R D I   O V A S  C U L  A R
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