Patrick Perier

Valve repair for mitral regurgitation caused by isolated prolapse of the posterior leaflet

BACKGROUND Although prolapse of the posterior leaflet is the most common abnormality of the mitral valve causing dysfunction, the long-term results of mitral valve repair for this condition are seldom reported. METHODS From October 1988 to June 1994, 208 patients (mean age, 59.4 years) with mitral regurgitation caused by isolated prolapse of the posterior leaflet underwent mitral valve repair alone or combined with myocardial revascularization (n = 30). The surgical techniques were quadrangular resection (n = 199) followed by annulus plication (n = 101) or sliding leaflet plasty (n = 98), use of artificial chordae (n = 5), or papillary muscle shortening (n = 4). All patients had an annuloplasty with a Carpentier ring. Mean follow-up was 3.4 +/- 0.1 years and total follow-up, 656 patient-years. RESULTS There were six operative deaths (2.9%). Postoperative Doppler echocardiography found two cases of systolic anterior motion (1%), and echocardiographic studies at follow-up showed satisfactory mitral valve function in 97% of 112 patients. At 6 years, the actuarial survival rate was 87% +/- 7%, and freedom from thromboembolic complications, bleeding complications, and reoperation was 93% +/- 7%, 95% +/- 3%, and 95% +/- 4%, respectively. CONCLUSIONS Mitral valve repair for regurgitation caused by prolapse of the posterior leaflet provides excellent survival at 6 years and should be considered the method of choice for its surgical treatment.

Carpentier "sliding leaflet" technique for repair of the mitral valve: early results.

Reconstructive mitral valve operation is now the preferred technique for the surgical treatment of prolapse of the posterior leaflet due to degenerative disease. Systolic anterior motion of the mitral valve with left ventricular outflow tract obstruction has been observed after such repair, with an incidence ranging from 4.5% to 10%. In an attempt to reduce the incidence of this complication, Carpentier has devised a new technique: the sliding leaflet plasty of the posterior leaflet. We report on 48 patients who underwent this new procedure between July 1990 and July 1992. One patient died perioperatively (2.1%). All other patients were able to be discharged on the ninth postoperative day. All patients underwent M-mode, two-dimensional, and Doppler echocardiography before discharge. Forty-one patients (85%) had no evidence of postoperative regurgitation, whereas 7 patients (15%) showed mild mitral valve insufficiency. Left ventricular outflow tract obstruction due to systolic anterior motion of the mitral valve was never detected. We believe that this technique of mitral valve repair is safe and seems to be effective in achieving a decreased incidence of left ventricular outflow tract obstruction.

Isolated cleft mitral valve: Valve reconstruction techniques

Reports concerning an isolated cleft of the anterior mitral valve are rare. This congenital anomaly of the mitral valve is usually repaired by suturing the edges of the cleft. We report 4 cases of isolated anterior mitral cleft. The patients ranged in age from 13 to 41 years. The clinical symptoms were those typical of mitral insufficiency. In all 4 patients, preoperative echocardiography was able to establish the exact anatomic diagnosis. In 1 patient, the cleft was directly sutured, whereas, in the other 3 patients, a fibrous reaction of the edges of the cleft with a subsequent lack of valvular tissue made direct suture technically impossible. Instead, the fibrous edges of the cleft were resected and the anterior leaflet of the mitral valve was reconstructed using an autologous pericardial patch pretreated with buffered glutaraldehyde. All 4 patients underwent annuloplasty together with placement of a Carpentier mitral ring. Postoperative echocardiograms have confirmed good results of the repair; 1 patient has a trivial insufficiency and 3 have a completely competent mitral valve.

Mitral Valve Repair in the Extensively Calcified Mitral Valve Annulus

Mitral valve replacement in patients with an extensively calcified mitral annulus is associated with an increased risk of ventricular rupture. Until now techniques of mitral valve repair have not been applied to patients with a heavily calcified mitral valve annulus. We present 12 patients who underwent extensive decalcification of the annulus with subsequent mitral valve repair between 1987 and 1990. Ages ranged from 11 to 78 years; 6 patients were in New York Heart Association functional class II, 4 were in class III, and 2 were in class IV. All patients had varying degrees of mitral insufficiency. There were no deaths, reoperations, or thromboembolic events. Postoperative echocardiography revealed minimal residual mitral insufficiency in only 2 of 12 patients. All patients are currently in New York Heart Association class I or II. We believe mitral valve repair can be done safely on patients with an extensively calcified mitral annulus, thus avoiding the risks of left ventricular rupture, thromboembolic events, and hemorrhagic complications associated with mitral valve replacement.

Long-Term Evaluation of the Carpentier-Edwards Pericardial Valve in the Aortic Position

From July 1980 to December 1985, 124 patients underwent isolated aortic valve replacement with the Carpentier‐Edwards pericardial bioprosthesis. The mean age of the patients was 64.9 ± 13.1 years. All patients but one (0.7%) were followed for an average of 5.52 ± 0.21 years after the operation and follow‐up totaled to 677 patient‐years. There were six early deaths (30‐day mortality of 4.8%) and 25 late deaths (3.7% ± 0.7% patient‐year). After 9 years the actuarial survival rate was 64% ± 14%. Six patients died of valve‐related deaths (three anticoagulant‐related hemorrhage, one endocarditis, one thromboembolic complication, and one sudden death) for an actuarial rate of 95% ± 5% patients free of valve‐related death at 9 years. Valve‐related complications included five thromboembolic episodes (0.7% ± 0.3% patient‐year), eight anticoagulant‐related hemorrhagic complications (1.2% ± 0.4% patient‐year), and two reoperations (0.3% ± 0.2% patient‐year). After 9 years, freedom from thromboembolic events was 96% ± 4%, that from anticoagulant‐related hemorrhage was 93% ± 5%, and that from reoperation was 98% ± 2%. There was no structural deterioration of the valve. We conclude that the Carpentier‐Edwards pericardial prosthesis has a low incidence of valve‐related complication and mortality within the 9‐year time frame of this study.

A 10-year comparison of mitral valve replacement with Carpentier-Edwards and Hancock porcine bioprostheses

Two hundred fifty-three patients who underwent isolated mitral valve replacement with a porcine bioprosthesis had long-term evaluation. One hundred forty-seven patients received a Carpentier-Edwards porcine bioprosthesis and 106, a Hancock valve. There were no significant differences in preoperative clinical characteristics between the two groups. Cumulative follow-up was 1,375 patient-years. At 10 years, 93% +/- 2.5% of the patients in the Carpentier-Edwards group and 85% +/- 7.8% of those in the Hancock group were free from valve-related death (not significant), and 95% +/- 2% and 91% +/- 3.8%, respectively, were free from thromboembolism (not significant). At 10 years, 65% +/- 7.2% of the patients in the Carpentier-Edwards group and 66% +/- 7.2% of those in the Hancock group were free from structural valve deterioration (not significant), and 64% +/- 6% and 59% +/- 7.3%, respectively, were free from reoperation (not significant). We conclude that the first generation of Carpentier-Edwards and Hancock prostheses produce comparable long-term results in the mitral position.

Rate of repair in minimally invasive mitral valve surgery

BACKGROUND Valve repair has been shown to be the method of choice in the treatment of patients with severe mitral valve regurgitation. Minimally invasive surgery has raised skepticism regarding the rate of repair especially for supposedly complex lesions, when anterior leaflet involvement or bileaflet prolapse is present. We sought to review our experience of all our patients presenting with degenerative mitral valve regurgitation and operated on minimally invasively. METHOD From September 2006 to December 2012, 842 patients (mean age 56.12±11.62 years old) with degenerative mitral valve regurgitation and anterior leaflet (n=82, 9.7%), posterior leaflet (n=688, 81.7%) and bileaflet (n=72, 8.6%) prolapses were operated on using a minimally invasive approach. RESULTS 836 patients had a valve repair (99.3%) and received a concomitant ring annuloplasty (mean size, 33.7; range, 28-40). Six patients (0.7%) underwent valve replacement. Two patients had a re-repair due to MR progression or infective endocarditis. Thirty-day mortality was 0.2% (two patients). There were 60 major adverse events (MAE) (7.1%). CONCLUSIONS A minimally invasive approach allows repair of almost all degenerative valves with good short-term outcomes in a tertiary referral center, when using proven and efficient surgical techniques.

Septal myectomy for left ventricular outflow tract obstruction after mitral valve repair

We describe a patient with a left ventricular outflow tract obstruction after mitral valve repair. Intraoperative transesophageal echocardiography permitted us to recognize the role of a bulging septum in the development of a systolic motion of the mitral valve. A left ventricular septal myectomy and myotomy was able to relieve the left ventricular outflow tract obstruction and the systolic anterior motion of the mitral valve.

The third generation Carpentier-Edwards bioprosthesis: early results.

The current status of valve replacement was reviewed by analyzing six groups of 100 consecutive patients, each receiving the standard Carpentier-Edwards bioprosthesis, the Starr-Edwards valve or the Björk-Shiley valve in the mitral or aortic position and operated on by the same surgeons in the same institution during an identical time frame. Data were evaluated for valve failure, reoperation, thromboembolism and valve-related deaths. Long-term results up to 9 years showed the superiority of bioprostheses over mechanical valves in terms of valve-related deaths and thromboembolic and anticoagulant complications for a similar rate of valve failure. Persistent drawbacks associated with valvular bioprostheses, namely, transvalvular gradients, limited durability and tissue calcification in young patients, led to continual improvements in valve design and preservation techniques and the development of the third generation Carpentier-Edwards bioprosthesis: the supraanular porcine valve and pericardial valve. The supraanular porcine valve was designed with the aim of decreasing the transvalvular gradient, decreasing turbulence, increasing longevity and decreasing calcification. The pericardial valve was designed with the aim of improving hemodynamics in small-sized orifices, improving mounting techniques to avoid fixation sutures at the commissures, achieving a flexible stent and improving preservation. Between July 1980 and October 1984, there were 391 supraanular porcine and 61 pericardial valves implanted. The supraanular valves were used for three purposes: isolated aortic, isolated mitral and mitral valve replacement associated with tricuspid anuloplasty. The pericardial valves were used for isolated aortic valve replacement. Short-term results (1 to 4 years) are presented concerning the clinical use of these third generation bioprostheses.

Minimally invasive repair of posterior leaflet mitral valve prolapse with the “respect” approach

Prolapse of the posterior leaflet (PPL) was the first lesion accessible for repair (1) and currently represents the most common cause of mitral regurgitation in a western population. Alain Carpentier conceptualized and developed the “functional approach” for mitral valve reconstruction, which aims to restore the coaptation surface (2). Leaflet resection followed by either annulus plication or sliding leaflet plasty has been the gold standard technique to repair PPL and has demonstrated excellent long-term results (3). More recently, an approach favoring leaflet tissue preservation has evolved (4). Over the years, mitral valve repair has been proven to demonstrate significantly better survival than mitral valve replacement (5,6). If mitral valve repair is carried out when the patient is still asymptomatic, surgery is expected to return their life expectancy to normal (7,8). Moreover, valve repair offers equivalent durability to a mechanical prosthesis without the burden of oral anticoagulation. After decades of intensive work, mitral valve repair has become the gold standard to surgically treat patients with mitral regurgitation. This major achievement has been demonstrated in patients operated via median sternotomy. Mitral valve repair has been a dynamic field with constant improvements, one of which has been to try to reduce surgical trauma via the minimally invasive approach. Alain Carpentier was the first to report mitral valve repair through a right thoracotomy with video assistance (9), and was soon followed by similar reports from others (10). Techniques have evolved, instrumentation has improved and today minimally invasive mitral valve repair has become a standard approach. The safety of the operation is similar to that of the sternotomy approach (11) and the long term results are satisfactory (12,13). This video describes the step-by-step repair of a PPL with a “respect” approach performed minimally invasively with total video assistance and no direct vision. The patient is a 42-year-old male patient in sinus rhythm. The patient is asymptomatic. He presented with severe mitral regurgitation, which was discovered during a routine examination. Preoperative echocardiography showed a prolapse of the PPL.