Introduction

Surgery is often needed for cases with multiple valve involvement where different therapeutic options can be used for the different valves. The dominant lesion and the degree of heart dilatation and dysfunction guide decision making(₁).Although its incidence is decreasing in western countries,rheumatic mitral disease is still frequent in developing countries. The decision to perform valve repair depends more on the extent of the etiology.

Case Presentation

Our case was a 40-year-old woman that had been followed with a diagnosis of rheumatic mitral and aortic stenosis diagnosis for 6 years. She was admitted to our Cardiology Outpatient Clinic for dyspnea and tachycardia. She was in New York Heart Association (NYHA) functional class III-IV at presentation. She had a AF rhythm in electrocardiography. Chest X-ray showed cardiomegaly(CTI:0.75),hilar congestion and flattening of pulmonary conus.Transthoracic echocardiography(TTE) showed severe MR(MVA:1.2cm²). Left ventricle EF was 60%. Other valves' functions included moderate aortic and tricuspid stenosis with regurgitation. Her cardiac coronary arteriography(CAG) was performed. It confirmed that EF was 60%. Coronary arteries were normal. She underwent operation.

She was operated under endotracheal general anesthesia and in supine position. Following a median sternotomy,pericardium was opened longitudinally. After heparinization, extra-corporeal circulation was established between the venae cavae and the ascending aorta. A cross clamp was placed on aorta and by retrograde continuous isothermic blood cardioplegia from coronary sinus,cardiac arrest was established.Hypothermia was moderate (28ºc). Insertion of a vent into right upper pulmonary vein was postponed until after left atriotomy due to proper bipolar ablation. Moreover, aortic exploration was left over since mitral repair and control with saline test were planned. Standard left atriotomy was made from interatrial junction. Our standard radiofrequency ablation technique was performed with Cardioblate BP(bipolar) Surgical Ablation Device (Medtronic 60821). Cross clamp duration lengthened 3-4 minutes with this accompanying procedure. The entire valvular apparatus was carefully examined in order to assess the feasibility of reconstructive surgery and to plan the operative technique. The valvular apparatus was then mobilized as an entire unit with a nerve hook in order to assess tissue flexibility and to identify leaflet restriction. It could cover whole mitral orifice and there wasn't any commissural fusion. The bilateral commissures were incised while leaving intact one milimeter of valvular tissue intact as in the normal anatomy (Figure 1).

Figure 1

Figure 1

After this step we performed bilateral segmental annuloplasty. This procedure may also be used to achieve better approximation of leaflet tissue with the placement of mattress stitches at the commissures. We tested the valve competence after this step on observing valve closure while the left ventricular cavity was filled with saline solution. There wasn't saline regurgitation.Valve competence and closure were excellent. Following right atriotomy, severe stenosis of the tricuspid valve was seen (Figure 2).

Figure 2

Figure 2

Anterior and septal leaflets were suspended with 3/0 polypropylene sutures. With the aid of these suspensory sutures, open commissurotomies were completed until annulus (Figure 3).

Figure 3

Figure 3

Control with saline test was optimal. Bilateral segmental annuloplasty was performed between anterior and posterior leaflets on the lateral side, whereas between anterior and septal leaflets on the other side. Commissural annuloplasty suture which was put after anteroposterior commissurotomy was serving for both strengthening the commissure and shrinking the posterior leaflet. Eventually, this valve was brought into a bicuspid form (Figure 4).

Figure 4

Figure 4

Aortotomy was made and aortic valve was identified as with 3 leaflets. Suspensory sutures were put on all of 3 commissures. Inspection of the valve revealed that there was a fusion of more than 1 cm between left and right coronary cusps, a fusion of more than 1 cm between right and non-coronary cusps and a fusion of 0.5 cm between non-coronary and left coronary cusps. There wasn't any tissue loss in any of these 3 leaflet structures. But advanced fibrotic thickenings were evident. Moreover, there wasn't any calcification observed (Figure 5).

Figure 5

Figure 5

Commissurotomies were performed to all 3 commissures. Pledgeted sutures were passed from inside aorta upwards in an oblique fashion so that pledgets remain under each commissure without obstructing commissural coaptation. This procedure was applied to all 3 commissures. All 3 leaflets with severe fibrotic thickening were shaven with a No. 15 scalpel blade in order to taper the leaflets. Then, peak points of these 3 leaflets (Arantius' nodules) were united temporarily with a single 4/0 polypropylene suture. It was identified that the valvular structure was optimal for coaptation (Figure 6). This temporarily placed suture was then removed. Left and right atriotomies and aortotomy were closed respectively.

Figure 6

Figure 6

Postoperative rhythm was sinusal. The volume of blood transfused was 2 units. The quantity of mediastinal drainage was 550 cc.She was extubated after an intubation duration of 11 hours and stayed in the intensive care unit for 2 days. The hospital stay was 11 days. Postoperatively on the discharge day and after 3 months an echocardiographic investigation was repeated. There wasn't any mitral regurgitation identified and mitral valvular area was 3.66 cm² (Figure 7).

Figure 7

Figure 7

Color Doppler echocardiographic images showed that gradients through mitral valve (mean gradient=4mmHg,peak gradient=7.17mmHg)were within normal limits

(Figure 8).

Figure 8

Figure 8

There was a mild tricuspid regurgitation identified with a pulmonary arterial pressure of 40 mm Hg (Figure 9).

Figure 9

Figure 9

M-mode imaging measured the aortic valve orifice as1.96 cm² (Figure 10).

Figure 10

Figure 10

The functional capacity of our patient improved dramatically and she was in NYHA functional class I-II. We found no postoperative cardiac decompensation symptom in our patient during late follow-up and she was followed at our outpatient clinic without additional problem.

Discussion

Mitral valve repair in rheumatic disease is technically difficult. It is now clearly established that restoration of a normal mitral valve function with reconstructive surgery is preferable to replacement with a device,whether bioprosthetic or mechanical(₂). Because avoidance of atrial fibrillation(AF) and its associated risks is a major goal of mitral valve repair,recent onset of AF has been established as another indication for the early operative correction of mitral insufficiency(₂,₃). The aim of mitral valve repair is to obtain a component mitral valve with the largest possible orifice and this repair represents a beter alternative than valve replacement,as previously described,in terms of a higher survival rate and a significant reduction in mitral valve-related complications(₃,₄).

Since 1970s,reconstructive surgery of the mitral valve was implanted definitively after the pioneering work of Carpentier(₅). Since then,clinical experience has shown that this conservative surgery involves minor hospital mortality and more satisfactory long-term clinical results(₆). Surgical techniques are evolving continuously and making it possible to treat lesions that we previously thought were beyond repair.

This repair is the least controllable and least symmetric and must be done judiciously.In all cases mitral valve competence should be tested by distending the ventricle with isotonic electrolyte(saline) solution. This maneuver will demonstrate any areas of residual leakage,which may be repaired by additional sutures(₇). The surgeon needs to observe the valve as many times as necessary before,during,and at the end of the procedure. The saline injection under pressure is favorable for checking the adequacy of the repair.Intraoperative saline test is safe but there was a 8% misleading ratio only(₈).

Atrial fibrillation(AF) is the most frequent rhythm disorder in population.It's frequency is 1% in general population and increases to 4% when age is over 60.This rate reaches to 50% in the cases operated rheumatic mitral valve disease(₉). If AF rhythm continues after mitral valve surgery,thromboembolic events increase and prevents the satisfactory function of heart.RF ablation especially during mitral valve surgery is a simple technique to be performed.Early results of cohort's are satisfying. At the one year follow-up time maintained sinus rhythm was 88.9% (₁₀).

Therapeutic indications differ depending on the aortic valvular lesion. The indication for surgical repair of aortic insufficiency depends on the impact on the left ventricle(₁). Aortic valvuloplasty (AoVP) is an established procedure regarded as a valid alternative for surgical management. However, its long-term efficacy in preventing or postponing aortic valve surgery remains uncertain for the individual patient(₁₁). Surgical aortic valvuloplasty is a valid option with good intermediate results for children and adolescents with aortic regurgitation from a variety of causes, particularly for patients with less than moderate aortic stenosis(₁₂). The long-term results of AoVP of congenital aortic valve stenosis in pediatric patients and its efficacy in preventing or postponing aortic valve surgery are very good. About two thirds of the patients are free from aortic valve surgery 10 years after AoVP(₁₁).

In the study of Pomerantzeff et al,their experience of aortic valve repair, consists of a small group of 39 patients. The results are satisfactory, but these techniques are feasible only in selected cases(₁₃).

The most common cause of tricuspid valve dysfunction is functional tricuspid regurgitation (TR) secondary to mitral valve disease(₁₄). For the tricuspid valve, valve repair is preferred over replacement as it results in a low gradient across the valve and obviates the risk of prosthesis-related complications(₁₅). Valve replacement is considered to be indicated only for those patients whose tricuspid valves have severe organic change or have been damaged by infective endocarditis(₁₄).

Correspondence to

Doç. Dr. Ufuk YETKİN 1379 Sok. No: 9,Burç Apt. D: 13 35220, Alsancak – İZMİR / TURKEY Tel: +90 505 3124906 Fax: +90 232 2434848 e-mail: ufuk_yetkin@yahoo.fr