[HSF] Redo Radical Mitral Valvuloplasty

[Hgrmd at aol.com]

Dear Members,
  Today's case was unusual.  About 2 years ago, I repaired a  myxomatous 
mitral in a 38 yo lady.  I placed 4 Goretex neochords in A1 and  A2.  I closed the 
P2-P3 interscallop leak, and performed a postero-medial  commissuroplasty.  A 
32 mm Physio ring was used.  She did well until a  few months ago when she 
was noted to have a recurrent MR murmur that was  asymptomatic.  TEE revealed 
mod-severe MR with a broad, largely central  jet.  I couldn't appreciate any 
recurrent prolapse.  There was mod TR,  normal coronaries, and an EF of 40%.  I 
operated this morning and found the  ring was intact and there was no prolapse. 
 I removed the ring, debrided  away the pannus, and inserted a 28 mm Physio.  
Saline test now revealed  broad restriction of P2 and P3.  I made a radial 
slit, 2mm from the ring,  along P2 and P3.  Gluteraldehyde treated autologous 
pericardium was then  used for posterior leaflet extension.  This was done with 
continuous 5-0  Cardionyl.  I also repaired the tricuspid (26mm MC3).  The 
post-CPB  TEE showed no MR or TR with an EF of 30%.  She was extubated on the 
table,  and did well thus far.  The main points are that rerepairing a valve is  
quite feasible.  Certainly, with her already depressed LV function, a  
replacement with a mechanical prosthesis would have severely clouded her  future.  
Hopefully, this repair will hold up, though it worries me that the  posterior 
leaflet restriction developed in the first place.  I presume it  was due to 
adverse ventricular remodeling.  Also, Dave Adams recently had a  paper in Annals 
in which he advocated using large rings for myxomatous  repairs.  However, I 
think this is potentially a mistake when doing  myxomatous repairs in hearts 
with impaired LV's.  For the myxomatous  repairs in hearts with relatively poor 
LV function, you should probably  undersize the ring much as you would for MR 
due to pure annular  dilatation.
Hal



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