Detection of mechanisms of immediate failure by transesophageal echocardiography in quadrangular resection mitral valve repair technique for severe mitral regurgitation

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Abstract

Residual mitral regurgitation (MR) after repair is a risk factor for late reoperation. The use of intraoperative transesophageal echocardiography (IOTEE) decreases the incidence of immediate repair failure. This study identifies the mechanisms of immediate failure by IOTEE in the quadrangular resection technique, a well-standardized mitral valve repair procedure to guide further repair procedures. Two hundred five consecutive patients underwent quadrangular resection due to prolapse or flail posterior leaflet. Twenty-four patients (11%) had immediate failure. Immediate reinstitution of cardiopulmonary bypass (“second pump run”) was needed in 21 patients (10%) for further repair. The identified mechanisms of failure were residual cleft provoking interscallop malcoaptation into the posterior leaflet in 8 patients, residual prolapse of the anterior or posterior leaflets in 1 and 4 patients, respectively, residual annular dilation in 3, left ventricular outflow obstruction in 2, suture dehiscence in 2, and other mechanisms in another 2 patients. In 20 patients (95%), IOTEE guided further repair with resolution of the residual MR, whereas 1 patient underwent valve replacement due to pharmacologically untreatable left ventricular outflow obstruction. In conclusion, even if this type of valve repair technique is well standardized, the incidence of immediate failure is not negligible. IOTEE identified the mechanisms of the immediate failure and guided further repair procedures, thus reducing the incidence of valve replacement (0.5%) without increasing perioperative mortality and morbility.

Section snippets

Study population

From January 2000 to December 2001, 206 consecutive patients with a diagnosis of prolapse or flail of the posterior leaflet underwent mitral valve repair. Of these patients, 205 underwent the quadrangular resection technique. These patients represent the study population group evaluated retrospectively (Table 1).

Surgical technique

The operations were performed by 3 surgeons (FM, LT, and OA). After midline sternotomy, cardiopulmonary bypass was instituted. Myocardial protection was obtained by cold blood

Results

Of the 205 patients submitted to quadrangular resection, 24 (11%) had immediate failure of the repair. The incidence of failure was not related to the surgeon who performed the operation or to the technique adopted (sliding vs no sliding plasty). Reinstitution of cardiopulmonary bypass (second pump run) was considered appropriate in 21 patients (10%) for further mitral valve surgery and in 2 patients (1%) exclusively to improve left ventricular function and eliminate MR (Figure 1). One patient

Discussion

By assessing leaflet motion, the origin and direction of the MR jet and left ventricular function were identified as most of the mechanisms of failure, with good agreement after surgery. As a first step in evaluating reasons for failure, one should rule out functional causes, such as left ventricular dysfunction and left ventricular outflow tract obstruction, because they are pharmacologically treatable conditions that do not need further surgical revision. However, despite these considerations

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