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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3740_Библиотеки_им_академика_М_И_Перельмана
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to leading edge
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Mural leaflet reattached to
annulus with 2-nes Cord,
Fig. 11.25 The completed repair with new cords to the leading edge
Cordal Replacement
Ruptured, stretched, or inadequate cord numbers can be
replaced by the use of 4′0′ Gore Tex sutures™. These are
placed through the appropriate papillary muscle head with
two passes (Fig.11.28) and then through the leading edge of
the leaet where needed, again with 2 passes per end of the
suture; as many sutures as are needed are used (Fig.11.29).
The leaet is then reduced to the appropriate height and
tested (Fig.11.30) and then tied. To prevent them slipping
once the correct length has been chosen each end of the
suture is passed behind the pair of sutures between the papil-
F. C. Wells
lary muscle and the leaet in both directions (Fig. 11.31).
When tied they will not slip and the knot will disappear
under the leaet when the valve is tensioned.
Commissural Prolapse
In this situation, both the aortic and mural leaets are
prolapsing at the end of the commissure. This is most commonly found at the junction of the infero-lateral end of the
commissure (Fig.11.32). There are several ways of dealing
with this but one is illustrated in Fig.11.33).
Aleri Edge-to-Edge Technique
This surgically simple solution is used primarily as a bail-out
manoeuvre for valves that the surgeon may feel are too complex to repair. Complex Barlow’s valves are often managed
by some surgeons in this way. Originally described by
Professor Aleri having come across a natural valve where
the centre of the valve leaets had fused in development, it
was originally described in the context of additional annular
reduction with the placement of an annuloplasty ring/band
[5]. It was named the edge-to-edge technique but this does
not accurately describe the placement of the sutures to
achieve lasting competence. Here the opposing edges of the
leaets are sewn directly together across the commissure in
the region of the prolapsing segments. The sutures must pass
as deep as the secondary cords with the rst pass of the needle and then through the leading edges (Fig. 11.34). The
suture is then tied turning the single mitral orice into a double orice valve. The repair is then stabilised with an annuloplasty ring. This is the basis of the Mitraclip™ percutaneous
method of repair, where instead of a suture one or more clips
are applied to x the leaets together. A commissural prolapse can also be repaired in this way but care must be taken
Trapezoid excision
ii
ii
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a
Oval excision
b
a
b
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i
Resultant force opens the cleft
i
a > b
Resultant force closes the clefts
Fig. 11.26 Trapezoidal resection of the base of the leaet after detachment from the annulus. This reduces the height but also pushes the edges
of the restored leaet towards the portion of leaet next to it allowing good coaptation between segments either side of the cleft
Fig. 11.27 Trapezoidal resection of the base of the leaet after detachment from the annulus. This reduces the height but also pushes the
edges of the restored leaet towards the portion of leaet next to it
allowing good coaptation between segments either side of the cleft
Fig. 11.28 Gore-Tex suture being passed through the papillary muscle
head
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F. C. Wells
a
b
c
Fig. 11.29 (a–c) Gore-Tex sutures passed through the leading edge of the leaet
a
Fig. 11.30 (a) Neo-cords in place ready to be tied down and the leaet is lowered to the appropriate height. (b) The valve is then tested to assess
the result
b
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ab
Fig. 11.31 (a, b) The sutures are then passed behind the afferent limbs of the suture and tied
Fig. 11.32 Infero-lateral commissural prolapse
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82
Hatch the resected
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F. C. Wells
ab
Commisural
prolapse
A
3
Commisural
leaflet
A
3
c
A
3
Incision
P
P
3
P
P
2/3
2
3
de
Reconstituted
leaflets sewn
back to
neo-annulus
Annuloplasty
ring
Annulus draw
outwards
Annuloplasty
sutures
Leaflet margins
drawn together
Fig. 11.33 (a–e) Each side of the prolapse is cut away from the annu-
lus, and the triangular corners are excised. The annulus is then drawn
backwards and sutured to itself, reducing the circumference of the
annulus and the leaets sewn back to each other. (f–h) The whole procedure is then stabilised with an annuloplasty band
M. Mural
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f
h
Fig. 11.33 (continued)
g
Alfieri Edge to edge technique.
A
M
A: Aortic
Fig. 11.34 Aleri edge-to-edge technique. Sutures pass through each
opposing leaet at the centre of the prolapse with the rst pass at the
level of the secondary cords
not to narrow the orice too much so as to produce mitral
stenosis. It is advisable to add an annuloplasty band to prevent later annular dilatation.
Annular Decalcication andReconstruction
It is quite common to nd calcication at the hinge of the
atrioventricular junction along the line of the mural leaet. It
occurs as a result of the excessive motion of the prolapsing
leaet and is found commonly in the Barlow’s valve. This
can be a short distance centred on the P2 region or in extreme
can extend for most of the orice of the valve with extension
into the aorto-mitral curtain extending into calcication of
the aortic valve (Fig.11.35). This can be the case with quite
mobile and uncalcied leaets making it the opposite of the
calcication found in rheumatic disease, where the primary
changes are in the leaets and the papillary muscles and the
cords. In such situations whether valve replacement or valve
repair is planned, the calcied tissue is best removed.
However considerable experience is needed to carry this out
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F. C. Wells
safely as rupture of the posterior wall of the ventricle can
occur if it is not done properly. Hence, it should be carried
out by experienced surgeons or under the direction of one
with experience.
Technique
Begin the process with a sharp incision into the endocardium
on the atrial side at the junction of the calcied tissue with
the calcium (Fig.11.36). This is extended for the length of
the calcied portion. The calcied block can then be teased
away from the ventricular muscle with a combination of
knife and scissors. It is usually possible to remove it in one
block (Fig.11.37). Occasionally the use of a Rangeur will
help. The one area that it is important to stay away from is
the P1/A1 region extending towards the outow tract of the
left ventricle. Extension of the removal into this area runs the
real risk of disassociation of the muscle underneath the left
atrial appendage with fatal results. This area of muscle will
separate and blood inltrating under pressure will burst
through underneath the left atrial appendage and is almost
impossible to repair.
Once the calcied block has been removed, it is essential
to cover the area with a large and loose pericardial patch to
prevent disruption of the posterior wall of the ventricle
through the now exposed muscle. The patch will be large to
prevent tension on the posterior wall when the ventricle is
functioning. The sutures in the ventricular muscle should be
deep and large bites through undisturbed muscle (Fig.11.38).
Sometimes there is enough excess tissue in the mural leaflet for it to be reconstituted (Fig.11.39). The annuloplasty
++
Ca
Begin the incision
at junction with
atrium
Fig. 11.36 The beginning of the incision into the endocardium at the
base of the calcied mass
Fig. 11.35 Radiograph of severe mitral annular calcication. In this
case almost circumferential
Fig. 11.37 (a, b) First incision to remove the calcied mass on the atrial side right on the reection of the endocardium from the mass
Pe
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a
P
1
Ventricular
muscle
P2 leaflet
P
3
85
Seperated
leaflet
Fat
++
Ca
resected
Exposed
muscle
in fat
b
Calcified spur
+
Ca
annulus
Pericardial
patch
ricardial patch
with leaflet
reattached
Fig. 11.38 (a, b) The calcied mass has been removed revealing the interatrial groove fat and exposed muscle. The mural leaet has been sepa-
rated from the calcied area. In (b), there was a calcied spur extending into the leaet which was then excised and the bare area patched
Cortex
cords
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F. C. Wells
Fig. 11.39 (a, b) A generous pericardial patch has been sewn into
position with no tension. The sutures for valve insertion are seen in
place in (b). In the rst case (a), there was enough leaet to reattach the
detached leaet to the neo-atrioventricular junction. Gore-Tex cords
were then inserted to the leading edge of the leaet
sutures should be placed through the junction of the pericardial patch and the atrial wall prior to reattachment of the
leaet.
If valve replacement is deemed necessary then again, the
sutures are passed through the patch and the atrial wall. This
will give a secure base for the valve annulus to be tied
against.
Barlow’s Valve
An extreme example of the Barlow’s deformity is shown in
Fig.11.40. Here almost all regions of the valve are prolapsing and have multiple clefts. Whilst bileaet prolapse is common in this setting, there are many cases where the aortic
leaet becomes unsupported as a result of severe mural leaflet prolapse. In this setting restoring mural leaet competence, with reduction of the annular circumference with an
annuloplasty band will reveal that the aortic leaet is not
actually prolapsing. These are cases where all of the tools in
the surgeon’s box may be required, leaet resection, leaet
height reduction, the use of neo-cords, etc. Experience is the
key to satisfactory results in these cases. Often multiple neocords are needed to both leaets. These are cases where signicant experience in the art of mitral surgery is needed.
The billowing nature of these valves leaves the surgeon
with a lot of excess leaet tissue that can be used to obtain
optimal results. It is important not to reduce the valve circumference any more than is necessary to give good leaet
coaptation as S.A.M. can easily be produced.
Fig. 11.40 An example of severe Barlow’s valve with ruptured cords
and multiple areas of prolapse and billowing leaets. It was possible
through a variety of techniques to reconstruct this valve
Endocarditis oftheMitral Valve
It is often possible to reconstruct endocarditic valves once all
infected material has been removed (Fig.11.41). It is important to be sure that excision is complete. Only then can it be
decided which reconstruction method may be applicable or
whether valve insertion is needed. Appropriate antibiotic
therapy should be continued for 6 weeks intravenously if
infected material is found at the time of surgery. As with
Barlow’s disease, the surgical techniques needed to resolve
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a
b
c
e
Fig. 11.41 (a–e) Endocarditis of the mitral valve with prominent gran-
ulation tissue attached to the aortic leaet. The degree of leaet inltration can be seen in (b). All infected material must be resected.
d
Depending upon the amount of remaining tissue, reconstruction with or
without pericardial augmentation may be possible
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