[HSF] small Mitral valve

[Michael Firstenberg]

During training, I always asked about doing mitral valve work thru  
the LV - but never saw one or got a good answer.  How do you do it?


-michael



On Dec 30, 2006, at 2:11 PM, Hgrmd at aol.com wrote:

> Dear Bob,
>   It may be easy to do a mitral repair via a left ventriculotomy  
> while  doing
> a Dor.  However, assuming you are talking about a Devega, it is  
> the  wrong
> operation for this type of pathology.  MR due to annular  
> dilatation  should be
> treated by a full rigid, or semirigid ring.  It's been amply   
> demonstrated that
> flexible, posterior repairs do nothing to decrease the  septal-lateral
> dimension or to prevent further anterior annular  dilatation.  To  
> me, the time
> required to open and close a left atriotomy is  well worth taking  
> so that a proper
> procedure can be carried out.
>   As long as procedures can be carried out expeditiously, and as  
> long  as
> proper attention to myocardial preservation is observed, I try to  
> do each
> procedure as best as it can be done.  Avoid shortcuts.  An   
> illustration is the case
> I did yesterday.  The 64 yo man was Class IV from  severe MR and  
> mod-severe
> TR.  The coronaries were normal and the EF was  50%.  He also had  
> PAF.  The TEE
> showed a flail posterior leaflet with  normal leaflet thickness.   
> Intraop, it
> looked like fibroelastic deficiency,  definitely not Barlowe's.  I
> resuspended P2 with 4 Goretex neochords and  installed a Physio.  I  
> also did a Cryomaze
> and repaired the tricuspid valve  with an MC3.  Coming off, there  
> was mild MR
> with good hemodynamics.  I  looked at the short axis view and  
> noticed that the
> jet was towards the posterior  commissure.  It also appeared that the
> posterior leaflet was mildly  tethered.  Obviously, I had made one  
> set of chords a
> little too  short.  I guarantee that a lot or most surgeons would  
> have left the
> mild MR  since the patient looked so good.  However, I went back on  
> and
> replaced the  set of chords in the posterior papillary muscle.  I  
> also did a
> posteromedial commissuroplasty with the "magic" stitch.  Additional  
> clamp  time was
> exactly 30 minutes.  The postop TEE was now perfect with zero  MR.   
> The depth
> of closure was 15 mm.  I felt much better, and the  patient was  
> fine this AM.
> Would he have done as well with the first  attempt at repair?   
> Probably, in
> the short term, but data shows even mild  MR adversely affects the  
> 10 year
> survival.
> Happy New Year to you and yours,
> Hal
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