Expanding the use of total mitral valve preservation in combination with implantation of the CarboMedics heart valve prosthesis.

BACKGROUND

Preservation of the mitral valve and subvalvular apparatus was introduced into the clinic in the early sixties, but for two decades the standard technique for mitral valve replacement included excision of both leaflets and their attached chordae tendineae. Lately, increased emphasis has again been placed on retention of the mitral subvalvular apparatus during valve replacement because of its role on left ventricular function.

METHODS

We have preserved the valvular and subvalvular mitral apparatus, when possible, in connection with mitral valve replacement during the last seven years and the present investigation (partly prospective and partly retrospective) was done with the aim of making up the results of our mitral preservation technique. In the period between January 1990 and December 1995, 30% of the patients who underwent mitral valve replacement had complete retention of all mitral tissue. In 1996, the percentage had increased to 50, and during the first seven months of 1997, 70% of the patients had complete retention of all mitral tissue. Since January 1997, we have exclusively used the CarboMedics mitral heart valve prosthesis. A total of 56 patients were identified to have had a CarboMedics heart valve prosthesis implanted. There were 33 men and 23 women with a mean age of 63 years, range 23-77 years. Coronary bypass was a concomitant procedure in 22 patients. In seven patients, both the mitral and aortic valves were replaced. A severely altered valve with thickened and or calcified leaflets, stenotic leaflets, or shortened, retracted and thickened chordae tendineae were not a contraindication for the procedure. Calcified plaques were removed. Adhesion between anterior and posterior leaflets was treated with sharp dissection. Valve and subvalvular tissue were preserved. The leaflets were reefed within the valve-sutures and compressed between the sewing ring and the native annulus when implanting the valve prosthesis. Chordal tension on the ventricle was thereby maintained and the chordae pulled away from the valve effluent. Echocardiography with measurement of ejection-fraction was performed preoperatively during the postoperative course in case of cardiac problems and on a routine basis 1 month after surgery and at various intervals when the patient was seen in the outpatient clinic. Left ventricular outflow tract gradients were measured during the postoperative course in case of cardiac problems and routinely 1 month postsurgically.

RESULTS

Five patients died in the postoperative period and one patient had transient neurological symptoms. In none of the patients was death or transient neurological symptoms a consequence of the retention of mitral leaflets with subvalvular apparatus. The remaining 51 patients were all alive at follow-up. Postoperative echocardiography demonstrated a preserved left ventricular function and a left ventricular outflow tract without obstruction.

CONCLUSIONS

We find that the described technique in combination with implantation of a CarboMedics heart valve prosthesis is very useful even in patients with a severely altered valve, when preserving the mitral leaflets with subvalvular apparatus during valve replacement. The technique is without procedure related complications and preserves left ventricular function without obstructing the left ventricular outflow tract.