Mitral valve repair: the Manipal alternative.

BACKGROUND AND AIM OF THE STUDY: An easily reproducible, rational and durable method of repairing the incompetent mitral valve, which does not require complex chordal procedures or the use of an expensive prosthesis and long-term anticoagulation, remains a desirable goal. Here, we describe such a method that has been developed at our institute. METHODS: The step-wise repair comprises: (i) preparation of a ring from a 3 x 110 mm strip of Dacron felt covered with untreated autologous pericardium; (ii) mitral commissurotomy and mobilization of the subvalvular apparatus, when required; (iii) infolding of the small portion of flail unsupported mitral leaflet, when present, by interrupted stitches; (iv) anchoring of the pre-prepared ring to the mitral annulus with interrupted horizontal mattress sutures, the sutures on the posterior annulus stopping short of the commissures by 12-15 mm and on the anterior annulus by 8-10 mm; (v) excision of the unanchored portions of the ring opposite the commissures, leaving behind 76-84 mm of the anchored parts; (vi) placement of two 'U-on-side' pericommissural annuloplasty sutures passed through the cut ends of the incomplete ring, then through the respective annulus, and finally emerging near the anterolateral and posteromedial commissures; and (vii) tying off the two pericommissural sutures over Teflon pledgets. RESULTS: Between January 1988 and December 1997, the technique was used to repair 107 mitral valves. Among 90 patients who had mitral valve repair alone or combined with tricuspid or aortic valve repair, only one hospital death occurred. One patient required reoperation due to an unacceptable degree of hemolysis. Among survivors followed up from one to >10 years, 80% were in NYHA functional class I, and 70% did not have clinical mitral regurgitation. CONCLUSION: This alternative technique of mitral valve repair is simple to perform, and relatively inexpensive. It provides gratifying results in acquired mitral valve disease, as well as in mitral valve prolapse subjects, and the repaired valve appears to function well, even after 10 years.

Tri-foliate pericardial patch repair of supra-valvular aortic stenosis.

Conventional aortoplasty procedures do not fully restore the normal anatomy in supra-valvular aortic stenosis (SVAS), which involves the sinus rim as well as the aortic cusps. A tri-sinus repair of this condition is proposed to restore the three intercommissural distances to normal and adequately replace the tissue loss of the sinuses, for a symmetrical reconstruction of the aortic root. Two patients, aged 3 and 11 years, with localized type of supra-valvular aortic stenosis were operated, in May 1994 and February 1996. The aortic stenosing ring was opened up at three points, by extending the incision into all the three sinuses, and the defect was repaired with in situ autologous pericardium, in a tri-foliate fashion. This repair achieved a symmetrical reconstruction of the aortic root and the systolic pressure gradient was completely abolished. Postoperative aortic root angiogram, in the older of the two patients, revealed a normal appearing aortic root. The patients have been followed-up for 51 months and 30 months respectively. Echocardiography showed competent aortic valves in both the patients without any systolic gradient across the aortic valve. A tri-sinus repair of the aorta in SVAS results in a symmetrical reconstruction of the aortic root by restoring the normal intercommissural distances of all the three cusps. It also abolishes the systolic pressure gradient. Autologous untreated pericardium lends itself easily for tailoring into a tri-foliate patch.

Tricuspid valve repair: a rational alternative.

BACKGROUND AND AIMS OF THE STUDY: The prosthetic ring annuloplasty and incompletely encircling suture techniques are effective methods of tricuspid valve repair when the problem is only annular dilatation, but not when organic tricuspid valve disease is present. A surgical technique of valve repair has been developed that is equally effective in correcting purely functional as well as organic valvular incompetence. METHODS: The Manipal method of repairing the incompetent tricuspid valve consists of three steps: (i) anteroseptal commissurotomy and asymmetric 'U-on-side' suture annuloplasty, to push the plane of coaptation of the anterior and septal leaflets into the right ventricle; (ii) a semicircular De Vega-type of plicating suture through the annulus, starting and ending just cephalad to the posteroseptal commissure and extending anticlockwise to a point just caudal to the meridian, to exclude the posterior leaflet; and (iii) tying the plicating suture after positioning a 3M Starr-Edward valve sizer across the tricuspid valve (in an adult), to ensure that the valve orifice is not excessively narrowed. RESULTS: Between July 1986 and January 1997, the Manipal method was used to repair 52 tricuspid valves, always combined with surgery for the mitral and/or aortic valve. Tricuspid stenosis of varying degree was present in 61% of cases. One of two hospital deaths was related to the repaired valve. Although the proportion of patients followed up fell progressively to 33% at 10 years, none of the patients either seen personally or who had replied to a postal questionnaire (78% of total patients) required reoperation for valve regurgitation or obstruction. No patient had more than mild tricuspid regurgitation clinically, even seven and 10 years after tricuspid valve repair surgery. CONCLUSION: This alternative method of tricuspid valve repair is simple to execute, is equally effective in correcting both pure tricuspid regurgitation and organic tricuspid valve disease, and appears to be extremely stable.

Fashioning of aortic isthmoplasty patch. A mathematical model.

BACKGROUND: Patch enlargement of the aortic isthmus in congenital coarctation of the aorta (aortic isthmoplasty) has been extensively performed since its introduction in 1957. Even after forty years, the size and shape of the prosthetic patch used as an on a graft is still determined, most of the time, empirically through eyeballing. Not infrequently, it has resulted in an ugly looking repaired aortic segment or with a significant residual systolic gradient across it. These twin problems have called for a mathematical model for designing the patch more precisely. METHODS: The model envisages a patch of the shape of an asymmetric octagon whose cranio-caudal length equals the distance from a point 8 mm on the proximal aorta to a point 8 mm on the distal dilated aorta on either side of the coarcted segment. The side to side length of the patch is determined by first subtracting the circumference of the narrowest part of the coarcted segment from the circumference of the distal dilated portion of the aorta and then adding 4 mm more. The larger slant sides of the octagon are obtained by joining the four smaller sides, of 8 mm in length each. Since July 1993 this mathematical model has been employed in 7 patients to prepare the exact size and the shape of the tightly woven low porosity Dacron patch. RESULTS: In each instance a neat cylindrical aorta was obtained without any measurable post-repair systolic pressure gradient across the repaired site. CONCLUSIONS: In view of these very satisfying results, we believe that this mathematical model of tailoring the patch has succeeded in converting the patch-aortoplasty procedure for coarctation of the aorta into a precise and hemodynamically fully corrective operation.

Pulmonary valve reconstruction in absent pulmonary valve syndrome: a new technique.

BACKGROUND: In patients with absent pulmonary valve syndrome, the relief of the pulmonary regurgitation at the time of primary repair improves both the early and late results. Though homograft and heterograft valves and conduits have been used for this purpose, both are not easily available and are known for late failure. Monocusp and bicuspid semilunar valves made out of pericardium have their own problems. Hence, a technique of reconstructing an autologous competent 3-cusp valve from the native tissues was developed. METHODS: Two posterolateral semilunar cusps were fashioned from the anterior wall of the main pulmonary artery. The anterior cusp was made from autologous pericardium stitched to the autologous pericardial patch used to widen the right ventricular outflow tract. RESULTS: This method of reconstruction was used in two patients aged 9 and 22 years, respectively. Visual assessment and passive testing after reconstruction revealed well functioning neopulmonary valves in both patients. The second patient, who had an unevenful hospital course, showed only mild pulmonary regurgitation at 5 years postreconstruction. CONCLUSIONS: As 2 of the 3 cusps are fashioned from the pulmonary arterial wall as a pedicled graft, we believe that they will retain their viability and grow with the pulmonary artery. Simultaneous reduction in the size of the pulmonary arteries will relieve bronchial compression when present. The anterior pericardial cusp, even if it eventually shrivels up, is unlikely to produce serious hemodynamic derangements.

Intraoperative assessment of mitral valve competence: a safe and reliable technique.

BACKGROUND AND AIMS OF THE STUDY: In mitral valve (MV) reconstructive surgery, the most difficult problem is immediate, intraoperative assessment of the repaired valve. We describe a simple technique of assessing the MV after the repair while the left atrium (LA) is still open. METHODS: The heart is perfused through a coronary line, after frustrating the MV with a multiholed disposable chest tube, and made to beat while the aorta is declamped. After de-airing, the frustrator is removed and the coronary line flow is gradually increased to one third of the arterial pump output. Within the blood filled pericardial well, through the opened LA, the MV is assessed for competence. The method allows for taking any corrective steps to achieve a competent MV before proceeding further. RESULTS: Over the last 10 years, the method was used in 106 patients undergoing MV repair. It allowed us to take corrective steps in all 31 patients (29.2%) who were found to have significant mitral regurgitation. No complication which could be attributed to the method of testing was documented. CONCLUSIONS: The method is found to be simple, safe, reliable, and has ensured against accepting less than optimal results.

Pulmonary pseudoaneurysm.

A case of pseudoaneurysm with erosion of both pulmonary and bronchial vessels is reported. The diagnosis was confirmed by computed tomography followed by intravenous digital subtraction angiography. It was removed surgically.

Drill biopsy in the diagnosis of lung lesions.

A high speed pneumatic drill was used to perform 190 percutaneous transthoracic biopsies in 161 patients. The resultant cores of tissue provided a definite diagnosis in 146 patients, giving a success rate of 90.7%. Complications occurred in 58 patients, subcutaneous emphysema being the most common, though only seven patients required active treatment, giving a rate of 3.7% for important complications. One patient died within 24 hours of the biopsy procedure owing to asphyxia resulting from aspiration of the contents of an acutely dilated stomach. Our experience clearly establishes that the drill biopsy as used by us is simple and safe and can be carried out in an outpatient department, yielding better overall results than any other procedure for closed biopsy of the lung currently practised.

A reappraisal of palliative surgery for total anomalous pulmonary venous connection: description of a new operative technique.

The need for effective palliation of critically ill infants born with total anomalous pulmonary venous connection is reappraised. Careful study of autopsy specimens in patients with this cardiac malformation (patient ages ranging from newborn to 5 1/2 mth) revealed 4 favorable anatomic dispositions in 16 selected hearts: (1) a horizontal vein or a lobar vein larger than 3-mm size was present in every case; (2) these veins were of adequate length for a shunt anastomosis; (3) the heart could be rotated for easy access to the left atrium; and (4) one of the two separate connecting veins in the mixed type could be utilized. Based on morphologic observations and trial procedures on the autopsy specimens, a new palliative operation is proposed which can be performed under normothermia and without cardiopulmonary bypass.