Edge-to-edge repair for mitral regurgitation associated with isolated double-orifice mitral valve

Edge-to-edge repair for mitral regurgitation associated with isolated double-orifice mitral valve Abstract We report the case of a patient with severe mitral regurgitation who was diagnosed with double-orifice mitral valve by preoperative transthoracic and transoesophageal echocardiography. During surgery, it was revealed that the mitral valve was divided into 2 orifices, anterolateral and posteromedial, by a fibrous bridging tissue that was supported by the chordae tendineae originating from an accessory middle papillary muscle. The posterior scallop of the anterolateral orifice was prolapsed due to chordal elongation. Six interrupted sutures were made between the anterior leaflet and the posterior leaflet at the prolapsed site. Additional interrupted sutures were made at the sites of 2 clefts, and a ring annuloplasty was added. Residual mitral regurgitation was trivial, and the mean postoperative pressure gradient through each orifice was approximately 6 mmHg. To the best of our knowledge, this is the first case report of an edge-to-edge mitral repair for mitral regurgitation associated with a double-orifice mitral valve. Double-orifice mitral valve, Mitral regurgitation, Edge-to-edge mitral repair INTRODUCTION An 80-year-old man with exertional dyspnoea had a regurgitant systolic murmur audible at the apex. Transthoracic echocardiography demonstrated severe mitral regurgitation (MR) due to prolapse of the posterior leaflet on the anterolateral side. 3D transoesophageal echocardiography (TOE) revealed that the mitral valve was divided unequally into 2 orifices. The anterolateral orifice (ALO) was smaller than the posteromedial orifice (PMO) (Fig. 1). Prolapse was observed at the anterolateral scallop of the posterior mitral leaflet of the ALO due to chordal elongation. During surgery, the TOE findings of double-orifice mitral valve (DOMV) were confirmed (Fig. 2A). The fibrous bridging tissue was supported by chordae tendineae connected to an accessory middle papillary muscle. The left-sided posterior scallop of the ALO was prolapsed due to chordal elongation, and there was a cleft on the posterior leaflet of the PMO and also at the right aspect of the bridging tissue. No concomitant congenital anomalies were detected. The prolapsed portion was closed with 6 interrupted sutures using 4-0 polypropylene. The 2 clefts were also closed with interrupted 5-0 polypropylene sutures. A mitral annuloplasty with a 28-mm Carpentier-Edwards Physio II ring (Edwards Lifesciences, Irvine, CA, USA) was added (Fig. 2B). Intraoperative TOE revealed trivial MR and no apparent mitral stenosis (MS). Postoperative transthoracic echocardiography demonstrated no MR and double mosaic inflows through the double orifices of the mitral valve both long axis (Video 1) and short axis (Video 2). The mitral valve area (MVA) and mean pressure gradient (MPG) of the patient were also measured. The MVA of the ALO was 1.1 cm2 using the planimetry method and 1.2 cm2 using the simplified Bernoulli equation, and the MPG was 6.1 mmHg. However, the MVA of the PMO was 1.8 and 1.9 cm2, respectively, and the MPG was 5.9 mmHg. The patient was discharged on the 18th postoperative day with an uneventful recovery. Figure 1: View largeDownload slide Preoperative transthoracic echocardiography (A) and transoesophageal 3D echocardiography (B) showing double-orifice mitral valve. ALO: anterolateral orifice; PMO: posteromedial orifice. Figure 1: View largeDownload slide Preoperative transthoracic echocardiography (A) and transoesophageal 3D echocardiography (B) showing double-orifice mitral valve. ALO: anterolateral orifice; PMO: posteromedial orifice. Figure 2: View largeDownload slide Intraoperative finding of a double-orifice mitral valve. (A) The mitral valve has 2 orifices, with a smaller orifice located anterolaterally and a larger orifice posteromedially. They are separated by fibrous bridging tissue (arrow). (B) The posterior scallop of the anterolateral orifice was prolapsed due to chordal elongation. Figure 2: View largeDownload slide Intraoperative finding of a double-orifice mitral valve. (A) The mitral valve has 2 orifices, with a smaller orifice located anterolaterally and a larger orifice posteromedially. They are separated by fibrous bridging tissue (arrow). (B) The posterior scallop of the anterolateral orifice was prolapsed due to chordal elongation. Video 1 Postoperative transthoracic echocardiography demonstrating no mitral regurgitation and double mosaic inflows through the double orifices of the mitral valve along the long axis. Video 1 Postoperative transthoracic echocardiography demonstrating no mitral regurgitation and double mosaic inflows through the double orifices of the mitral valve along the long axis. Close Video 2 Postoperative transthoracic echocardiography demonstrating no mitral regurgitation and double mosaic inflows through the double orifices of the mitral valve along the short axis. Video 2 Postoperative transthoracic echocardiography demonstrating no mitral regurgitation and double mosaic inflows through the double orifices of the mitral valve along the short axis. Close DISCUSSION DOMV is a rare malformation and is often associated with other congenital anomalies. In particular, it is not uncommon for DOMV to be associated with an atrioventricular defect. Tomita et al. [1] reported a successful DOMV repair involving reconstruction with artificial chordae. However, this technique remains controversial, because there have been very few patients with this condition. Yamasaki et al. [2] reported that a patient required re-repair 1 year after the initial surgery due to detachment of the artificial chordae that had anchored the immature papillary muscle. In our case, an accessory middle papillary muscle connected to the bridging fibrous tissue and the prolapsed site was located in the smaller orifice. Therefore, exposure of the subvalvular apparatus was poor. For these reasons, we chose the edge-to-edge technique [3] because of its simplicity. When the edge-to-edge technique is adopted, MS should be monitored. We calculated that MS would be avoided, because the size of the prolapse was limited. Intraoperative TOE after cardiopulmonary bypass weaning demonstrated trivial MR and no apparent MS. We measured MVA, as an indicator of MS severity, using both the planimetry and the simplified Bernoulli equation methods, which resulted in surprisingly similar calculated total areas of 2 orifices of 3 cm2, indicating mild MS. The simplified Bernoulli equation is widely accepted for the assessment of transvalvular pressure gradients and identification of stenosis [4]. However, its use for measuring across an asymmetric DOMV remains controversial [5]. The MPG through both the ALO and the PMO was approximately 6 mmHg (5–10 mmHg is considered moderate MS). We believe that this is the first case report of an edge-to-edge repair for DOMV. The follow-up period is still short; therefore, a longer follow-up is mandatory. ACKNOWLEDGEMENTS The authors are grateful to Yoko Motomura for her assistance. Conflict of interest: none declared. REFERENCES 1 Tomita Y, Yasui H, Tominaga R. Mitral valve repair for isolated double-orifice mitral valve with torn chordae. Ann Thorac Surg  1997; 64: 1831– 4. http://dx.doi.org/10.1016/S0003-4975(97)01070-9 Google Scholar CrossRef Search ADS PubMed  2 Yamasaki M, Misumi H, Abe K, Kawazoe K. Challenging mitral valve repair for double-orifice mitral valve with noncompaction of left ventricular myocardium. Gen Thorac Cardiovasc Surg  2017; 65: 650– 2. Google Scholar CrossRef Search ADS PubMed  3 Maisano F, Torracca L, Oppizzi M, Stefano PL, D’Addario G, La Canna G et al.   The edge-to-edge technique: a simplified method to correct mitral insufficiency. Eur J Cardiothorac Surg  1998; 13: 240– 6. Google Scholar CrossRef Search ADS PubMed  4 Shernan SK. Perioperative transesophageal echocardiographic evaluation of the native mitral valve. Crit Care Med  2007; 35: S372– 83. Google Scholar CrossRef Search ADS PubMed  5 Trzcinka A, Fox JA, Shook DC, Hilberath JN, Hartman G, Bollen B. Echocardiographic evaluation of mitral inflow hemodynamics after asymmetric double-orifice repair. Anesth Analg  2014; 119: 1259– 66. Google Scholar CrossRef Search ADS PubMed  © The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Interactive CardioVascular and Thoracic Surgery Oxford University Press

Edge-to-edge repair for mitral regurgitation associated with isolated double-orifice mitral valve

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© The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
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Abstract

Abstract We report the case of a patient with severe mitral regurgitation who was diagnosed with double-orifice mitral valve by preoperative transthoracic and transoesophageal echocardiography. During surgery, it was revealed that the mitral valve was divided into 2 orifices, anterolateral and posteromedial, by a fibrous bridging tissue that was supported by the chordae tendineae originating from an accessory middle papillary muscle. The posterior scallop of the anterolateral orifice was prolapsed due to chordal elongation. Six interrupted sutures were made between the anterior leaflet and the posterior leaflet at the prolapsed site. Additional interrupted sutures were made at the sites of 2 clefts, and a ring annuloplasty was added. Residual mitral regurgitation was trivial, and the mean postoperative pressure gradient through each orifice was approximately 6 mmHg. To the best of our knowledge, this is the first case report of an edge-to-edge mitral repair for mitral regurgitation associated with a double-orifice mitral valve. Double-orifice mitral valve, Mitral regurgitation, Edge-to-edge mitral repair INTRODUCTION An 80-year-old man with exertional dyspnoea had a regurgitant systolic murmur audible at the apex. Transthoracic echocardiography demonstrated severe mitral regurgitation (MR) due to prolapse of the posterior leaflet on the anterolateral side. 3D transoesophageal echocardiography (TOE) revealed that the mitral valve was divided unequally into 2 orifices. The anterolateral orifice (ALO) was smaller than the posteromedial orifice (PMO) (Fig. 1). Prolapse was observed at the anterolateral scallop of the posterior mitral leaflet of the ALO due to chordal elongation. During surgery, the TOE findings of double-orifice mitral valve (DOMV) were confirmed (Fig. 2A). The fibrous bridging tissue was supported by chordae tendineae connected to an accessory middle papillary muscle. The left-sided posterior scallop of the ALO was prolapsed due to chordal elongation, and there was a cleft on the posterior leaflet of the PMO and also at the right aspect of the bridging tissue. No concomitant congenital anomalies were detected. The prolapsed portion was closed with 6 interrupted sutures using 4-0 polypropylene. The 2 clefts were also closed with interrupted 5-0 polypropylene sutures. A mitral annuloplasty with a 28-mm Carpentier-Edwards Physio II ring (Edwards Lifesciences, Irvine, CA, USA) was added (Fig. 2B). Intraoperative TOE revealed trivial MR and no apparent mitral stenosis (MS). Postoperative transthoracic echocardiography demonstrated no MR and double mosaic inflows through the double orifices of the mitral valve both long axis (Video 1) and short axis (Video 2). The mitral valve area (MVA) and mean pressure gradient (MPG) of the patient were also measured. The MVA of the ALO was 1.1 cm2 using the planimetry method and 1.2 cm2 using the simplified Bernoulli equation, and the MPG was 6.1 mmHg. However, the MVA of the PMO was 1.8 and 1.9 cm2, respectively, and the MPG was 5.9 mmHg. The patient was discharged on the 18th postoperative day with an uneventful recovery. Figure 1: View largeDownload slide Preoperative transthoracic echocardiography (A) and transoesophageal 3D echocardiography (B) showing double-orifice mitral valve. ALO: anterolateral orifice; PMO: posteromedial orifice. Figure 1: View largeDownload slide Preoperative transthoracic echocardiography (A) and transoesophageal 3D echocardiography (B) showing double-orifice mitral valve. ALO: anterolateral orifice; PMO: posteromedial orifice. Figure 2: View largeDownload slide Intraoperative finding of a double-orifice mitral valve. (A) The mitral valve has 2 orifices, with a smaller orifice located anterolaterally and a larger orifice posteromedially. They are separated by fibrous bridging tissue (arrow). (B) The posterior scallop of the anterolateral orifice was prolapsed due to chordal elongation. Figure 2: View largeDownload slide Intraoperative finding of a double-orifice mitral valve. (A) The mitral valve has 2 orifices, with a smaller orifice located anterolaterally and a larger orifice posteromedially. They are separated by fibrous bridging tissue (arrow). (B) The posterior scallop of the anterolateral orifice was prolapsed due to chordal elongation. Video 1 Postoperative transthoracic echocardiography demonstrating no mitral regurgitation and double mosaic inflows through the double orifices of the mitral valve along the long axis. Video 1 Postoperative transthoracic echocardiography demonstrating no mitral regurgitation and double mosaic inflows through the double orifices of the mitral valve along the long axis. Close Video 2 Postoperative transthoracic echocardiography demonstrating no mitral regurgitation and double mosaic inflows through the double orifices of the mitral valve along the short axis. Video 2 Postoperative transthoracic echocardiography demonstrating no mitral regurgitation and double mosaic inflows through the double orifices of the mitral valve along the short axis. Close DISCUSSION DOMV is a rare malformation and is often associated with other congenital anomalies. In particular, it is not uncommon for DOMV to be associated with an atrioventricular defect. Tomita et al. [1] reported a successful DOMV repair involving reconstruction with artificial chordae. However, this technique remains controversial, because there have been very few patients with this condition. Yamasaki et al. [2] reported that a patient required re-repair 1 year after the initial surgery due to detachment of the artificial chordae that had anchored the immature papillary muscle. In our case, an accessory middle papillary muscle connected to the bridging fibrous tissue and the prolapsed site was located in the smaller orifice. Therefore, exposure of the subvalvular apparatus was poor. For these reasons, we chose the edge-to-edge technique [3] because of its simplicity. When the edge-to-edge technique is adopted, MS should be monitored. We calculated that MS would be avoided, because the size of the prolapse was limited. Intraoperative TOE after cardiopulmonary bypass weaning demonstrated trivial MR and no apparent MS. We measured MVA, as an indicator of MS severity, using both the planimetry and the simplified Bernoulli equation methods, which resulted in surprisingly similar calculated total areas of 2 orifices of 3 cm2, indicating mild MS. The simplified Bernoulli equation is widely accepted for the assessment of transvalvular pressure gradients and identification of stenosis [4]. However, its use for measuring across an asymmetric DOMV remains controversial [5]. The MPG through both the ALO and the PMO was approximately 6 mmHg (5–10 mmHg is considered moderate MS). We believe that this is the first case report of an edge-to-edge repair for DOMV. The follow-up period is still short; therefore, a longer follow-up is mandatory. ACKNOWLEDGEMENTS The authors are grateful to Yoko Motomura for her assistance. Conflict of interest: none declared. REFERENCES 1 Tomita Y, Yasui H, Tominaga R. Mitral valve repair for isolated double-orifice mitral valve with torn chordae. Ann Thorac Surg  1997; 64: 1831– 4. http://dx.doi.org/10.1016/S0003-4975(97)01070-9 Google Scholar CrossRef Search ADS PubMed  2 Yamasaki M, Misumi H, Abe K, Kawazoe K. Challenging mitral valve repair for double-orifice mitral valve with noncompaction of left ventricular myocardium. Gen Thorac Cardiovasc Surg  2017; 65: 650– 2. Google Scholar CrossRef Search ADS PubMed  3 Maisano F, Torracca L, Oppizzi M, Stefano PL, D’Addario G, La Canna G et al.   The edge-to-edge technique: a simplified method to correct mitral insufficiency. Eur J Cardiothorac Surg  1998; 13: 240– 6. Google Scholar CrossRef Search ADS PubMed  4 Shernan SK. Perioperative transesophageal echocardiographic evaluation of the native mitral valve. Crit Care Med  2007; 35: S372– 83. Google Scholar CrossRef Search ADS PubMed  5 Trzcinka A, Fox JA, Shook DC, Hilberath JN, Hartman G, Bollen B. Echocardiographic evaluation of mitral inflow hemodynamics after asymmetric double-orifice repair. Anesth Analg  2014; 119: 1259– 66. Google Scholar CrossRef Search ADS PubMed  © The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

Journal

Interactive CardioVascular and Thoracic SurgeryOxford University Press

Published: Mar 1, 2018

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