[HSF] Redo Radical Mitral Valvuloplasty

[Demertzis Stefanos]

I am impressed of the high quality discussions on this topic. So much that I'd like to contribute to the discussion with a recent failure of mine: 76 yr old male with good EF, mitral regurgitation and hypertrophied interventricular septum. The mitral regurgitation was due to prolaps between P2 and P3 and annular dilatation. What seemed to be a straight forward repair case yielded several problems: in the OR the prolaps was due to a thinned and multiperforated interscallop tissue between P2 and P3 and in addition there was a prolaps of the A1 and P1. The latter was corrected with two  artificial Goretex-chordae. For the strange posterior problem I simply sutured the P2 and P3 together (first error). I put an 28 mm Physioring in measuring the intercommissural distance (second error). The surgical test (filling the LV with saline) was ok (single drops of leakage with filled LV). The TEE showed significant residual regurgitation so I went back and re-checked. My impression was that the chorda on P1 was to tight, so I redid it and the result looked better. Again the TEE showed significant regurg, so obviously I did not capture where the real problem was. The regurg was not constant but appeared every 7th or 8th heart beat and more frequently after extrasystoles. The repair looked morphologically fine. Analyzing the pictures with and without regurg we identified SAM and the Ventouri effect due to septal hypertophy as the main mechanism. To conclude, after a third period of cold blood cardioplegia I decided to replace the valve preserving the posterior leaflet and two connections between the AML and the papillary muscles, not wanting to end with a forth approach to the valve after another try to repair it. Obviously I was not very pleased with the end result but I felt this was the correct decision for the safetly of the patient. Debriefing the case I think the first error was not to resect (ergo reducing the height of the PML) and the second error was to place a too small ring in and not trusting to my eye-judgment. Both errors together with the hypertophy of the septum contributed to the appearance of SAM and to the failure of the repair.

Stefano Demertzis, MD, PhD

Cardiocentro Ticino
Lugano - Switzerland



-----Original Message-----
From: openheart-l-bounces at lists.hsforum.com on behalf of rwmfglycar at aol.com
Sent: Sun 2007-06-03 12:00
To: OpenHeart-L at lists.hsforum.com
Subject: Re: [HSF] Redo Radical Mitral Valvuloplasty
 
My own bias is that subaortic septal hypertrophy is a more important factor than the angle by itself
The septal bulge produces the increase in velocity that can drag the anterior leaflet towards it. 
If ever you have to spend the night at  the Johannesburg Oliver Tambo airport, stay at the Sun Hotel and have your dinner in Bernouilli's restaurant. The walls are decorated by great black and white photo's of propellers and wings and clouds interspersed with blown up facsimiles of fluid dynamic mathematical formulae,
Bob

-----Original Message-----
From: Hgrmd at aol.com
To: OpenHeart-L at lists.hsforum.com
Sent: Sat, 2 Jun 2007 9:24 pm
Subject: Re: [HSF] Redo Radical Mitral Valvuloplasty



Prasanna,
 Not off hand. It's similar to what some U.S. judge said when  what should 
e considered obscene.  "I know it when I see it."  A  narrow mitral-aortic 
ngle leaves little room in the LVOT to accommodate the  anterior leaflet.

al

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