Z Kardiol 90: Suppl 6, VI/75 – VI/80 (2001) © Steinkopff Verlag 2001

Jörg-Friedrich Onnasch Felix Schneider Marco Mierzwa Friedrich Wilhelm Mohr

 Mitralklappenrekonstruktion vs. Mitralklappenersatz  Zusammenfassung In den letzten 40 Jahren hat die Mitralklappenchirurgie einen grundlegenden Wandel erfahren. Der initialen Begeisterung nach der Einführung von Klappenprothesen in den 60er Jahren folgte eine Renaissance der Rekonstruktion der Mitralklappe mit der Vorstellung der Ringannuloplastie-Technik in den 70er Jahren. Die Rekonstruktion der Mitralklappe erhält die Integrität der subvalvluären Strukturen, die eine entscheidende Rolle für die linksventrikuläre Funktion spielen. Große Studien, die sowohl Früh- als auch Langzeitergebnisse nach Mitralklappenrekonstruktionen gegenüber prothetischem Klappenersatz betrachteten, zeigten eine geringere Operationsmortalität sowie eine deutlich höhere Langzeitüberlebensrate bei Patienten nach Mitralklappenrekonstruktion. Weiterhin

J.-F. Onnasch () · Dr. F. Schneider M. Mierzwa · Prof. Dr. F. W. Mohr Klinik für Herzchirurgie Herzzentrum Universität Leipzig Strümpellstr. 39 04289 Leipzig, Germany Tel.: +49-341/865-1421 Fax: +49-341/865-1452 E-Mail: [email protected]

Mitral valve repair versus mitral valve replacement

sind spezifische Probleme, wie Thromboembolien oder Endokarditis, die bei Klappenersatzverfahren auftreten können, zu nennen. In Anbetracht dieser Tatsachen sind klappenerhaltende Rekonstruktionstechniken von Vorteil. Jedoch ist die Entscheidung für eine Mitralklappenrekonstruktion von unterschiedlichen Faktoren abhängig, wie der Ätiologie der Mitralklappenerkrankung und der daraus folgenden Pathomorphologie der Klappe, sowie patientenabhängigen Einflüssen, wie z.B. Alter oder Kontraindikationen für eine Antikoagulationstherapie und nicht zuletzt der Erfahrung des Chirurgen. Somit ist der Prozess der Wahl eines geeigneten Operationsverfahrens sehr komplex und individuell von jedem Patienten abhängig zu machen. Sowohl Studiendaten als auch Datenbanken großer Patientenkollektive reflektieren die Vorteile der Mitralklappenrekonstruktion mit einem Rekonstruktionsanteil von bis zu 75 % in der gesamten Mitralklappenchirurgie. In den letzten 5 Jahren wurde der videoassistierte Zugang zur Mitralklappe über eine rechtslaterale Minithorakotomie zu einem etablierten Verfahren entwickelt. Dieser minimalinvasive Zugang erlaubt sowohl komplexe Rekonstruktions- als auch Klappenersatzverfahren unter anderem mit

gerüstfreien Bioprothesen. Zusätzliche chirurgische Verfahren, wie die linksatriale Hochfrequenzablation zur Herstellung eines Sinusrhythmus bei Patienten mit Vorhofflimmern, verbessern das Operationsergebnis nach Mitralklappenchirurgie sowohl hinsichtlich der kardialen Funktion als auch der Lebensqualität für den Patienten deutlich und können ebenfalls über den minimalinvasiven Zugang durchgeführt werden.  Schlüsselwörter Mitralklappe – Ersatz-Rekonstruktion – minimalinvasive Operationstechniken  Summary Over the past 40 years mitral valve surgery has changed dramatically. After initial enthusiasm with the introduction of valve prostheses in the 1960s, a renewed interest in repair techniques began in the 1970s with the introduction of annuloplasty rings. These repair techniques revealed that the integrity of the subvalvular apparatus plays an important role in left ventricular function. When considering the major series comparing early and late results of mitral valve repair versus prosthetic mitral valve replacement, operative mortality rate is lower for patients with mitral valve repair. Long-term results also show a superior survival rate after mitral valve recon-

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struction. In addition, several problems can occur with the prosthetic valve, such as thromboembolism and endocarditis. All of these factors favor valve repair over replacement. The success of mitral valve repair depends on many factors: etiology of the mitral valve disease and the resultant pathomorphology of the valve, patient’s circumstances such as age or contraindication for anticoagulation, and the experience of the surgeon. The decision whether to repair or

replace the mitral valve depends on these factors. Data in the literature and in large collective databases reflect the advantages of mitral valve repair, with over 75 % of current mitral valve surgeries being repairs. In the past 5 years the exposure of the mitral valve through a right lateral minithoracotomy using video assistance has developed into a widespread technique. This approach allows complex mitral valve repair as well as mitral valve

replacement even with biological stentless prostheses, with decreased morbidity. The addition of radiofrequency ablation for restoration of sinus rhythm enhances the outcome after mitral valve surgery, and can also be easily performed through a minithoracotomy technique.  Key words Mitral valve – replacement – repair – minimally invasive surgery – left atrial ablation

Introduction

Mitral valve regurgitation

The surgical treatment of mitral valve disease has developed far beyond its early beginnings. The earliest attempts at reconstruction of the mitral valve were performed in the case of mitral stenosis at the beginning of the 20th century [4, 40]. The introduction of cardiopulmonary bypass in 1953 allowed open access to the mitral valve to perform mitral valve repair in the case of mitral insufficiency. With the introduction of prosthetic valves in the early 1960s, which were initially used to treat aortic valve disease, they were soon used to replace the mitral valve as well. Subsequently most surgeons had turned to valve replacement, believing that replacing the valve was better than repair. Despite advancements in technology and the introduction of better prostheses, complications using mechanical mitral valve prostheses persist to some degree even to the present. These include thromboembolism, hemolysis, mechanical failure, transvalvular gradients, infection and paraprosthetic leakage. Bioprostheses in the mitral valve position showed significant rates of structural deterioration [5]. A renewed interest in mitral valve repair began in the 1970s, when annuloplasty rings were introduced by Carpentier et al. [8] and Duran and Obago [13]. Today, much experience has been gained with both repair and replacement. Competence of the mitral valve depends on the structural and functional integrity of the valves constituent components: the annulus, the leaflets, the tendinous cords, the papillary muscles, and the supporting left ventricular myocardium. It is also necessary to appreciate the mitral valve relationship to the aortic valve – the overlapping of the inlet and outlet tracts of the left ventricle. Abnormalities of any of these structures can alter mitral valve functioning in important ways. Hence the pathomorphology of the different mitral valve diseases and pathophysiological aspects as well as the hemodynamic considerations influence the decision to repair or replace the valve.

In the majority of patients, mitral regurgitation is the result of decreased coaptation of the leaflets. The incidence of different etiologies have changed over the past 30 years in the western world from predominantly rheumatic in the 1960s to the floppy mitral valve today due to myxomatous degeneration or ischemic heart disease. Mitral regurgitation may be primary, caused by pathological changes in the valve and the supporting apparatus, or secondary to dilatation of the valve ring due to left ventricular disease. Carpentier described a systematic classification of abnormalities of the mitral valve leaflets, annulus, and subvalvular structures: type I, normal leaflet motion; type II, prolapsed leaflet; and type III restricted leaflet motion [7]. The mitral regurgitation in the single classification types was ascribed to different reasons: type I, annular dilatation or leaflet perforation; type II prolapse of one leaflet caused by ruptured or elongated chordae, or ruptured papillary muscle or dysfunction of papillary muscle; type III, comissural fusion, leaflet thickening or associated fused chordae. There are three options for the surgical correction of mitral valve pahtology: conservation of the valve using reconstructive techniques, total excision of the mitral valve and replacement with a mechanical or tissue prosthesis, and insertion of a valve prosthesis with preservation of one or both leaflets and their subvalvular apparatus. The optimal procedure has been the subject of much debate. The continuity of the subvalvular apparatus has an important role in the ventricular function. It has been shown experimentally to account for as much as 25% of the left ventricular systolic function [16, 24]. In light of these numbers, there are several reports demonstrating improved results of mitral valve repair over replacement, if the subvalvular apparatus is resected [23, 41]. In addition posterior ventricular wall rupture following mitral valve replacement without chordal preservation has

J.-F. Onnasch et al. Mitral valve repair versus mitral valve replacement

raised concerns [15]. These findings explain the renaissance of interest in mitral valve conservation and repair techniques. To evaluate the decision making for mitral valve repair, echocardiography has become the bench-marking tool. It provides precise information about the mitral valve and the left ventricle. This information includes valve pathomorphology including any calcification, leaflet motion and flexibility and their relative size, size of annulus, morphology and length of chordae and papillary muscle function, and, finally, the direction of the regurgitation jet. In addition to the preoperative diagnosis, intraoperative transesophageal echocardiography supports the surgeon’s decision and allows the surgeon to control the efficacy of the repair before decannulation [10]. The surgical techniques of mitral valve repair have been developed continuously. Carpentier´s classification of abnormalities has become the foundation on which most surgeons base their decision. The aim of mitral valve repair is not the reconstruction of normal valve anatomy but the restoration of normal valve function. Most commonly, partial or complete prosthetic annuloplasty rings are used in type I mitral valve incompetence. Leaflet perforations as seen in bacterial endocarditis can be repaired with pericardial patches [25]. Localized prolaps (type II mitral valve incompentence) can be managed by resection of a segment of the leaflet. If it involves the anterior leaflet or most of the posterior leaflet, some form of chordal reconstruction such as chordal transfer or chordal repair is needed [18, 39]. Polytetrafluorethylene suture material allows chordae replacement with sustained good results [17, 47]. Other techniques such as sliding plasty and Alfieri-plasty complete the complexity of mitral valve repair. The hospital mortality rate for surgical treatment of ischemic mitral valve regurgitation remains higher than the average mortality rate for other cardiac procedures. In the case of true ischemic mitral valve regurgitation, valve repair has been shown to carry better results than mitral valve replacement [6, 12, 37]. It has been shown that under hemodynamic aspects mitral valve conservation and surgical repair appears to be beneficial for those patients in whom it is possible, but in several cases repair of the mitral valve has been impossible. This may be due to extensive degeneration or calcification of the leaflets or commissures or extensive leaflet prolapse. The preservation of the mitral subvalvular apparatus has been demonstrated to improve postoperative left ventricular function. This argument led to the idea of preserving the subvalvular structures in the case of mitral valve replacement as well. Already in the 1960s Lillehei et al. suggested that preservation of the subvalvular apparatus during mitral valve replacement might prevent low cardiac output in the early postoperative phase [29], but this observation was overlooked by

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most surgeons for many years. A renewed interest in this technique began in the 1980s when some authors reported a clear difference in left ventricular function between patients who underwent mitral valve replacement with or without preservation of the subvalvular apparatus. These results were confirmed in several studies [16, 26, 34]. A number of techniques for preserving the subvalvular structures have been described [13, 31]. Most common is the preservation of the posterior leaflet because it is technically easy and there is no potential interaction with mechanical valve leaflet motion and no need to undersize the mitral prosthesis, and no possibility of creating a LV outflow tract obstruction. Some authors prefer the bileaflet preservation and showed an early postoperative improvement in LV function as compared to only posterior leaflet preservation, but in followup studies there were no significant differences between the complete versus partial chordal preservation groups [26, 38, 46]. If the decision to replace the valve has been made, the selection whether a mechanical or bioprosthetic valve should be used depends on many factors: patient’s age, profession, presence of atrial fibrillation and contraindications to anticoagulative therapy. With the possibility of restoration of sinus rhythm in the case of atrial fibrillation using additional radiofrequency ablation, a bioprosthesis should be the valve of choice in elderly patients and patients with contraindications for anticoagulation [45]. The superior results of mitral valve repair compared to replacement concerning the physiological and hemodynamic aspects have been pointed out, but this is only one aspect. In addition to these arguments, there are additional problems that occur after valve replacement with a prosthesis. These prosthesis-related problems include thromboembolic events, endocarditis, structural valve failure and paraprosthetic leakage. These problems are less likely in mitral valve repair [9]. The clinical results of mitral valve repair have been documented in a number of series and some general conclusions can now be made. Despite its greater technical complexity, mitral valve repair is associated with a lower surgical mortality rate than prosthetic mitral valve replacement and provides better survival rates [11, 21, 35]. Controversy remains as to the long-term freedom from recurrent mitral insufficiency but long-term results show excellent results for mitral valve repair. Reoperation rates are routinely reported to be lower than those for prosthetic valves. Follow-up studies over 20 years describe a remarkably steady improvement in New York Heart Association functional class and free cardiac event rates up to 74 %. Furthermore the survival rates after repair were better than replacement (19.5 years: 30 ± 7% vs. 22 ± 4 %) [3, 33]. These facts demonstrate that in degenerative mitral valve regurgitation, the gold standard operation should be a valve repair.

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Mitral valve stenosis In mitral valve stenosis the picture is completely different. Mitral valve stenosis can be either congenital or acquired. Because of additional cardiovascular defects with a high mortality rate, congenital mitral valve disease is seen rarely in adults. In the majority, acquired mitral valve stenosis results from rheumatic fever. The pathomorphology of the valve following history of rheumatic fever shows calcification and thickening of the whole functional apparatus of the valve. Characteristic is the fusion of the commissures which restricts the mobility of the leaflets. The results in the literature and the statements whether to repair or replace the valve in the case of mitral valve stenosis reflect the various experiences of the authors. Cortufo et al. report in their series that longterm results of mitral valve commissurotomy were more satisfactory than those obtained with bileaflet valves; however, the reoperation rate was significantly higher in the commissurotomy group [14]. Duran et al. desribed a higher hospital mortality in the replacement group as compared to the repair group but also a significantly higher reoperation rate in long-term follow-up when the valve was initially repaired [20]. Percutaneous mitral dilation for treating mitral valve stenosis has developed to a widely accepted technique but traumatic insufficiency secondary to this procedure is still a problem and decreases the feasibility of surgical mitral valve repair due to anatomic lesions [1]. New repair techniques such as debridement using the rasping procedure may be promising but the long-term results remain unclear [27]. The pathology of rheumatic mitral valve stenosis is extremely variable and variably progressive. Even in ideal cases, which are suitable for commissurotomy by whatever technique, the continuing pathologic process may result in a recurrence of valvular obstruction in time. The pathology of mitral valve stenosis and the progression process depend on many factors: age, social status, medical treatment and care, etc. Reflecting these facts, the decision whether to repair or replace the valve is not solely limited to the state of total pathology at the time of intervention. The choice is specific to the patient’s pathology, to the patient’s social circumstances, to the surgeon’s skills and to the healthcare resources [22]. A possible answer could be a valve prosthesis that will duplicate the natural valve in form and function. Early results of the chordally supported stentless mitral valve [Quadricusp mitral valve (QMV)] are promising. The papillary flaps support the anterior and posterior leaflet providing annuloventricular continuity to support left ventricular function which results in physiological hemodynamics and impairment of left ventricular function. The valve is relatively easy to implant even using a

right lateral minimal access procedure. The early results, clinical and hemodynamic, were satisfactory [44]. However the long-term results especially the question of effectiveness of the anticalcification treatment of the valve prosthesis have to be evaluated.

Discussion There is no unique answer to the question whether to repair or replace the mitral valve. Concerning the advantages of mitral valve repair, data in the literature and the databases, show a repair rate in overall mitral valve surgery of approximately 75 % [42]. For successful repair, no aspect of the technical side is more important than adequate exposure of the mitral valve. Following the remarks by Randall [36], many surgeons would agree that the best visualization of mitral valve is not through a median sternotomy, but through the right chest approach. With the introduction of video systems, new surgical instruments and cardiopulmonary bypass systems a number of efforts have been made to minimize the chest incision, which has paved the way for a “paradigm shift” in mitral valve surgery. A right lateral minithoracotomy using a 4 to 5 cm incision in the 4th intercostal space offers optimal exposure of the mitral valve and allows complex repair techniques with a beneficial outcome for the patient not only cosmetically but also in avoiding rib retraction and minimizing dissection of the heart [44]. Atrial fibrillation is a common complication in mitral valve disease due to moderately or greatly enlarged left atrium. As a consequence, the left ventricular function is impaired and thromboembolism is possible. To enhance the outcome after mitral valve repair in restoring physiological left heart hemodynamics, the adoption of intraoperative radiofrequency ablation for chronic atrial fibrillation (IRAAF) is a method with promising results. In addition, the patient’s quality of life is improved by avoiding anticoagulation. However, surgical repair of the mitral valve is far more complex than mitral valve replacement and demands a higher level of intraoperative decision-making and a full understanding of any lesions that are possible. It is essential to be realistic in the discussion with patients and referring physicians regarding the operative strategy. There is a learning curve for the decision-making tree for every surgeon performing mitral valve surgery, but with sensible selection due to valve pathomorphology and patient’s circumstances satisfactory results can be achieved in mitral valve repair as well as in mitral valve replacement.

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[Mitral valve repair versus mitral valve replacement].

Over the past 40 years mitral valve surgery has changed dramatically. After initial enthusiasm with the introduction of valve prostheses in the 1960s,...
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