Repair of Mitral Incompetence Secondary to Ruptured Chordae Tendineae

Manhas, Dev R.; Hessel, Eugene A.; Winterscheid, Loren C.; Dillard, David H.; Merendino, K. Alvin

doi:10.1161/01.cir.43.5.688

Cited by 31 publications

(7 citation statements)

References 22 publications

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“…Rather than plication we have preferred to excise the redundant wedge of leaflet, suturing the cut edges together with interrupted sutures. This procedure, first described by Hessel et al (1966) and again by Manhas et al (1971), has produced excellent initial results in our four patients, ailthough the follow-up is still quite short. Recently, Kerth, Sharma, Hill, and Gerbode (1971) have stated that the late results for a plication repair in the centre of the posterior leaflet are very good.…”

Section: Number and Situation Of Ruptured Chordaesupporting

confidence: 60%

Non-rheumatic `subvalvar' mitral regurgitation: Surgical pathology and results of operation in 37 patients

Caves

Paneth

1973

Thorax

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Tlhirty-seven patients with non-rheumatic subvalvar mitral regurgitation are reported, representing 16% of all patients with mitral regurgitation submitted to open operation over a five-and-a-halfyear period.In 22 older patients with 'idiopathic' chordal lesions, the commonest finding was rupture of chordae to the posterior leaflet. The aortic leaflet chordae were most frequently involved following myocardial infarction (7 patients) or bacterial endocarditis (3 patients). Three other younger patients had ruptured chordae and two patients had rupture of the posteromedial papillary muscle following acute myocardial infarction.The mitral valve was repaired in 16 patients with ruptured chordae, of whom only eight obtained a satisfactory late result. In the other 21 patients the valve was replaced with a mounted aortic homograft or a Starr-Edwards prosthesis. It is concluded that mitral valve repair should be reserved for patients with symmetrical rupture of the chordae controlling the centre of the posterior leaflet, as regurgitation may reappear after other forms of repair due to progressive rupture of other abnormal chordae or breakdown of the repair.The early and late mortality in the patients with a definite antecedent myocardial infarction was much higher than in the other groups, and emergency valve replacement soon after rupture of the papillary muscle was unsuccessful in both patients.In a previous report (Caves, Sutton, and Paneth, in press) we have defined non-rheumatic 'subvalvar' mitral regurgitation as the result of deformity, disruption or dysfunction of the chordae tendineae or papillary muscles in the absence of primary disease of the leaflets or annulus, and have discussed the aetiology and clinical findings. This paper describes the operative findings, surgical technique, and results in 37 patients with 'subvalvar' mitral regurgitation. Thirty-three of these patients were included in the previous report.MATERIAL AND regurgitation was due to non-rheumatic rupture or stretching of the chordae tendineae (35 patients) or rupture of the posteromedial papillary muscle (2 patients). The remainder (188 patients) either gave a definite history of rheumatic fever or were found at operation to have evidence of chronic rheumatic valve disease. In some of these patients ruptured chordae were also seen, but only as part of the rheumatic disorganization of the valve structures.Forty-four operations were performed in the 37 patients, seven patients requiring a second operation. Surgery was performed with the aid of a rotating disc pump oxygenator primed with blood/ Ringer's lactate solution. The chest was opened through a median sternotomy and the mitral valve was exposed trans-septally through the right atrium.All patients who left hospital were followed up by personal examination or by information received from the referring cardiologist. In assessing postoperative improvement, particular attention was paid to the plain chest radiograph as well as to the patient's symptoms. It has recently been shown at this h...

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Section: Number and Situation Of Ruptured Chordaesupporting

confidence: 60%

Non-rheumatic `subvalvar' mitral regurgitation: Surgical pathology and results of operation in 37 patients

Caves

Paneth

1973

Thorax

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“…Direct interpretation of these results, however, is limited by the fact that the patients who had reconstructive procedures necessarily represent a selected group and may not be strictly comparable with those who had valve replacement. The structural damage to the mitral valve causing mitral regurgitation which is still amenable to conservative procedures has been variously defined in (Steinmetz et al, I962;Anderson et al, I962;Aldridge et al, I966;Reed, I968;Gerbode et al, I968;Rumel et al, I969;Kerth et al, 1971;Manhas et al, 197I;Dubost, I971;Messmer et al, I973), and the proportion of patients considered suitable for reconstructive operations ranging from 20 to 85 per cent, as reported in different series (Rumel et In the present series mitral annuloplasty was not attempted if the mitral valve was grossly damaged or calcified as assessed during operation. The patients selected were mainly those with isolated mitral regurgitation caused by dilatation of the mitral ring, with minimal involvement of the valve or subvalvular structures and with little or no calcification of the cusps.…”

Section: Discussionmentioning

confidence: 99%

Clinical and haemodynamic results of mitral annuloplasty.

Pakrashi¹,

Mary²,

el-Mufti³

et al. 1974

Heart

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Clinical results were evaluated 6 months to I4 years after mitral annuloplasty in 89 operative survivors. Before operation, 13 patients were grade 2, 63 grade 3, and I3 grade 4 (N. Y.H.A. classification). After operation all patients were improved symptomatically. Sixty-one patients were grade I, 27 grade 2, and I patient grade 3. Early clinical deterioration occurred in 5 patients, caused by dehiscence of annuloplasty in 3, and by infective endocarditis in 2, within six months of the operation. Progression of mitral valve disease was responsible for late deterioration I to 8 years after mitral annuloplasty in 23 patients. Sixteen needed mitral valve replacement. There were 12 deaths, including 6 after reoperation. Actuarial analysis showed go per cent survival with annuloplasty at 5 years' and 6o per cent at I0 years' follow-up. Late systemic embolism occurred in only 3 cases though anticoagulants were not used.Haemodynamic studies in I4 unselected patients, 5 to II years after annuloplasty, showed significant reduction in pulmonary wedge andpulmonary arterialpressure when compared with the preoperative values.In view of the satisfactory long-term clinical results, as observed in this study, mitral annuloplasty merits consideration in the surgical treatment ofmitral regurgitation.Despite considerable advances over the past decade, the prevailing uncertainty in the long-term prognosis after mitral valve replacement (Ellis, I967; Ross, I972; Behrendt and Austen, I973) underlines the need for reappraisal of other methods of mitral valve surgery. Mitral annuloplasty, for the correction of mitral regurgitation, was introduced before valve replacement became established (Lillehei et al., 1957; Merendino and Bruce, I957) and this institution was one of the centres to pioneer the technique (Wooler et al., I962). The present study was undertaken to assess the clinical and haemodynamic results after mitral annuloplasty, and to evaluate its relative merits in the surgical treatment of mitral regurgitation. Subjects and methodsThe study group comprised 89 operative survivors of mitral annuloplasty performed between 1957 and I973. There were 75 women and 14 men in the series and their age distribution, ranging from 8 to 66 years (mean 38-4 years), is indicated in Table I. At the time of operation 13 patients were in grade 2, 63 in grade 3, and I3 in

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“…Manhas et al described in 1971 22 CTR cases that were operated on in the University Hospital of Seattle, Washington, among which 7 (31.8%) were considered primary, 9 RHD, 6 had SBE (including 2 cases that had both SBE and RHD), 1 trauma, and 1 aortic regurgitation [11].…”

Section: Primary Literature Reviewmentioning

confidence: 99%