VALVULAR HEART MSEASE
Doppler Echocardiographic Comparison of the Carpentier and Duran Anuloplasty Rings Versus No Ring After Mitral Valve Repair for Mitral Regurgitation Brigitte Unger-Graeber, MD, Richard T. Lee, MD, Martin St. John Sutton, MRCP, Maureen Plappert, John J. Collins, MD, and Lawrence H. Cohn, MD
To compare the hemodynamic results of different amdoplasty techniques of primary valve repair for mitral regurgitation, 122 patients were prospectively studied with Doppler echocardiograms 5 to 10 days after operation. Seventy-seven patients had mitral valve prolapse, 27 had coronary artery diwase, 13 patients had rheumatic mitral valve lesions and 5 patients had infective endocarditis. Forty-eight patients received the flexible Duran ring, 46 received the more rigid Carpentier ring and 26 patii received no ring. Doppler echocardiography demonstrated a significant decrease in mitral valve area estimated by the pressure halftime method in patients who received either a Carpentier (2.6 f 0.8 cm*) or Duran ring (2.8 f 0.8 cm*) when compared with patients who received no ring (3.2 f 0.7 cm*) (p = 0.01). No significant differences were observed for peak transmitral diastolic velocity, peak transmitral diastolic gradient, or the grade of mitral regurgitation by color flow Doppler mapping between patients with and without rings. The etiology of mitral disease and concomitant surgical procedures accompanying mitral valve repair did not significantly influence mitral valve area, peak velocity or peak gradient. These data suggest that Carpentier and Duran rings decrease the hemodynamic mitral valve area; however, the decrease in valve area is small and not associated with a clinically important increase in transvalvubr gradient. (Am J Cardiil 1661;67:517-519)
From the Cardiovascular Division, Department of Medicine, and the Division of Cardiac Surgery, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts. Manuscript received August 10, 1990; revised manuscript received October 29,1990, and accepted October 3 1, Address for reprints: Lawrence H. Cohn, MD, Division of Cardiac Surgery, Brigham and Women’s Hospital, 75 Francis Street, Boston, Massachusetts 02115.
itral valve repair to correct mitral valve regurgitation has been in use for >30 years.1-3Successful mitral valve repair results in lower operative mortality, late mortality, reoperation rates and valve-related complications compared with mitral valve replacement.4,5Mitral valve repair may decreasethe frequency of postoperative low-output syndrome because it preservesthe natural geometry of the left ventricle by maintaining papillary muscle integrity.6*7 In addition, long-term studies have indicated that mitral valve repair may be more durable than bioprosthetic replacement.8,9Several different techniques of mitral valve repair have been used. Carpentier et allo modified mitral valve repair by the insertion of a semiflexible ring; a more flexible ring was developed by Duran et al.” This study comparesearly postoperative hemodynamic results of mitral valve repair with either the Carpentier or Duran ring versus repair with no ring.
M
METHODS
Between January 1984 and September 1989, 166 patients with pure mitral regurgitation were treated with mitral valve repair at Brigham and Women’s Hospital. Of these patients, 122 (81 men and 41 women, mean age f standard deviation 62 f 13 years) were randomly selected to receive postoperative Doppler echocardiograms5 to 10 days postoperatively. Seventysevenpatients had mitral valve prolapse,27 patients had coronary artery disease,13 patients had rheumatic mitral valve lesions and 5 patients had active infective endocarditis (Figure 1). Patients with hemodynamic evidence of preoperative mitral stenosis were excluded from the study. Operative technique: The wide variety of pathology treated in this group necessitateda multitude of techniques including anterior and posterior leaflet resection, trench chordoplasty, the flip-over technique for chordal replacement, and 3 different forms of treatment to the anulus. The decisionregarding the use of different rings or no ring dependedon a variety of factors. The Carpentier ring was used earlier in our experience, but as we increased our experience with myxomatous mitral valve repair we have shown that the more flexible Duran ring appears to be preferable for these very enlarged anuli. The Carpentier ring often “telescopes” the large amount of tissue of the dilated floppy valve into THE AMERICAN JOURNAL OF CARDIOLOGY MARCH 1. 1991
517
TABLE Valve
I Influence Function
Etiology Myxomatous lschemic Rheumatic Endocarditis
of Etiology
on Early Postoperative
TABLE II Influence of Repair Technique Postoperative Mitral Valve Function
Mitral
MVA (cm2)
PeakV(m/s)
Gradient (mm Hg)
2.8 f 2.9 f 2.8 f 2.7zk
1.3f0.3 1.3f0.3 1.5f0.3 1.2f0.3
7.0 7.3 8.9 5.6
0.9 0.7 0.8 1.0
f f f f
1
3.7 2.7 3.5 3.2
No ring Carpantier ring bran ring
No significant influence of etiology on Doppler parameters was detected. Gradent = peak transmitral diastolic gradlent; WA = mitral valve area: Peak V = peak transmitral early diastolic velocity.
on Early
MVA (cmZ)
Peak V (m/s)
Gradient (mm Hg)
3.2 f 0.7 2.6 f 0.8% 2.8 f 0.9*
1.2f0.4 1.4 f 0.3 1.3 f 0.3
6.5 f 3.9 8.0 f 3.1 6.9 f 3.5
* Significantly diierent from no ring (p
Doppler Echocardiographic Comparison of the Carpentier and Duran Anuloplasty Rings Versus No Ring After Mitral Valve Repair for Mitral Regurgitation Brigitte Unger-Graeber, MD, Richard T. Lee, MD, Martin St. John Sutton, MRCP, Maureen Plappert, John J. Collins, MD, and Lawrence H. Cohn, MD
To compare the hemodynamic results of different amdoplasty techniques of primary valve repair for mitral regurgitation, 122 patients were prospectively studied with Doppler echocardiograms 5 to 10 days after operation. Seventy-seven patients had mitral valve prolapse, 27 had coronary artery diwase, 13 patients had rheumatic mitral valve lesions and 5 patients had infective endocarditis. Forty-eight patients received the flexible Duran ring, 46 received the more rigid Carpentier ring and 26 patii received no ring. Doppler echocardiography demonstrated a significant decrease in mitral valve area estimated by the pressure halftime method in patients who received either a Carpentier (2.6 f 0.8 cm*) or Duran ring (2.8 f 0.8 cm*) when compared with patients who received no ring (3.2 f 0.7 cm*) (p = 0.01). No significant differences were observed for peak transmitral diastolic velocity, peak transmitral diastolic gradient, or the grade of mitral regurgitation by color flow Doppler mapping between patients with and without rings. The etiology of mitral disease and concomitant surgical procedures accompanying mitral valve repair did not significantly influence mitral valve area, peak velocity or peak gradient. These data suggest that Carpentier and Duran rings decrease the hemodynamic mitral valve area; however, the decrease in valve area is small and not associated with a clinically important increase in transvalvubr gradient. (Am J Cardiil 1661;67:517-519)
From the Cardiovascular Division, Department of Medicine, and the Division of Cardiac Surgery, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts. Manuscript received August 10, 1990; revised manuscript received October 29,1990, and accepted October 3 1, Address for reprints: Lawrence H. Cohn, MD, Division of Cardiac Surgery, Brigham and Women’s Hospital, 75 Francis Street, Boston, Massachusetts 02115.
itral valve repair to correct mitral valve regurgitation has been in use for >30 years.1-3Successful mitral valve repair results in lower operative mortality, late mortality, reoperation rates and valve-related complications compared with mitral valve replacement.4,5Mitral valve repair may decreasethe frequency of postoperative low-output syndrome because it preservesthe natural geometry of the left ventricle by maintaining papillary muscle integrity.6*7 In addition, long-term studies have indicated that mitral valve repair may be more durable than bioprosthetic replacement.8,9Several different techniques of mitral valve repair have been used. Carpentier et allo modified mitral valve repair by the insertion of a semiflexible ring; a more flexible ring was developed by Duran et al.” This study comparesearly postoperative hemodynamic results of mitral valve repair with either the Carpentier or Duran ring versus repair with no ring.
M
METHODS
Between January 1984 and September 1989, 166 patients with pure mitral regurgitation were treated with mitral valve repair at Brigham and Women’s Hospital. Of these patients, 122 (81 men and 41 women, mean age f standard deviation 62 f 13 years) were randomly selected to receive postoperative Doppler echocardiograms5 to 10 days postoperatively. Seventysevenpatients had mitral valve prolapse,27 patients had coronary artery disease,13 patients had rheumatic mitral valve lesions and 5 patients had active infective endocarditis (Figure 1). Patients with hemodynamic evidence of preoperative mitral stenosis were excluded from the study. Operative technique: The wide variety of pathology treated in this group necessitateda multitude of techniques including anterior and posterior leaflet resection, trench chordoplasty, the flip-over technique for chordal replacement, and 3 different forms of treatment to the anulus. The decisionregarding the use of different rings or no ring dependedon a variety of factors. The Carpentier ring was used earlier in our experience, but as we increased our experience with myxomatous mitral valve repair we have shown that the more flexible Duran ring appears to be preferable for these very enlarged anuli. The Carpentier ring often “telescopes” the large amount of tissue of the dilated floppy valve into THE AMERICAN JOURNAL OF CARDIOLOGY MARCH 1. 1991
517
TABLE Valve
I Influence Function
Etiology Myxomatous lschemic Rheumatic Endocarditis
of Etiology
on Early Postoperative
TABLE II Influence of Repair Technique Postoperative Mitral Valve Function
Mitral
MVA (cm2)
PeakV(m/s)
Gradient (mm Hg)
2.8 f 2.9 f 2.8 f 2.7zk
1.3f0.3 1.3f0.3 1.5f0.3 1.2f0.3
7.0 7.3 8.9 5.6
0.9 0.7 0.8 1.0
f f f f
1
3.7 2.7 3.5 3.2
No ring Carpantier ring bran ring
No significant influence of etiology on Doppler parameters was detected. Gradent = peak transmitral diastolic gradlent; WA = mitral valve area: Peak V = peak transmitral early diastolic velocity.
on Early
MVA (cmZ)
Peak V (m/s)
Gradient (mm Hg)
3.2 f 0.7 2.6 f 0.8% 2.8 f 0.9*
1.2f0.4 1.4 f 0.3 1.3 f 0.3
6.5 f 3.9 8.0 f 3.1 6.9 f 3.5
* Significantly diierent from no ring (p
