[HSF] Redo Radical Mitral Valvuloplasty

[Prasanna Simha M]

I agree that downsizing is probably wise if it will not lead to  SAM. The
normal mitral circumference is 10cms and that means you would not need to
have  a diameter more than that. Also an MVOA of > 2.0 sq cm  will always
have acceptable gradients even with exercise.One important thing is that
bigger is not necessarily better, Thus placing  a large prosthesis in the
mitral position may not be better (and an article in JVHD corroborates
this). My reasoning is that  having a smaller prosthesis or a ring will
allow remodeling of the ventricle and will reduce its spherecity so
implanting a large prosthesis  (where leaflet weight versus flow will not
necessarily reduce gradients (unlike in an aortic position where prostheses
are generally smaller) and  will "splint" the annulus in a "diastolic"
position which will increase ventricular spherecity and would thus decrease
ventricular function.The sphincteric function of the mitral annulus is lost
with all rigid / semirigid repairs (I have pictures with radioopaque
flexible rings showing annular motion being preserved - I think I showed
them once in HSF) and so I think it is better to fix it at predicted
systolic circumference/ dimensions compared to diastolic diastolic / flaccid
dimensions.

Myxomatous valves can be rerepaired and I congratulate you on this.
Unfortunately the  rheumatic ones which have progressed have all been due to
posteromedial pericommissural (p3 retraction) which I have not been able to
rerepair.
Did you by any chance do a sliding plasty in your original repair ? One
possible cause in my mind could due to fibrosis after a sliding
plasty.Didthe pannusby any chance extend on to the leaflet ?
Prasanna


On 6/2/07, Hgrmd at aol.com <Hgrmd at aol.com> wrote:
>
> 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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-- 
Prasanna Simha M