There are many ways to repair a mitral valve and I have always liked the “tool box” concept.  In other words, I think that you have to be prepared to use different techniques, for similar pathologies, in different patients.  I think that you cannot resort to only one technique to repair all valves. Not all valves are created equally.

I have been using the loop technique now for all anterior leaflet repairs and occasionally for posterior leaflet repairs. I know that everyone has there own concepts and tricks on using loops. I think that for the anterior leaflet the loops should be in front of the papillary muscles and for the posterior leaflet the loops should be behind them.  The trick here is that the loops need to be positioned between the chords when they are being attached to the posterior leaflet. I think that this concept is more anatomical from a chordal standpoint. The mitral collar provides unimpeded visualization of the entire infra-valvular apparatus. Furthermore, a mini-thoracotomy approach provides direct in-line, truly anatomical visualization of the mitral valve.

I would be interested in what others think.

1. The first picture shows the loops to the anterior leaflet positioned to the anterior aspect of the papillary muscle. The posterior loops are behind the papillary muscle and are tied anterior to the papillary muscle. The tied knot to the posterior loops is visualized anteriorly.

2. The second picture shows the posterior loops behind the papillary muscle and positioned between the individual chords. In other words, all the loops are not brought around the entire set of chords.

I truly believe that the easiest way to perform a septal myectomy is through the mitral valve. The majority of cases that have severe MR secondary to SAM and septal hypertrophy will have a small anterior leaflet. There have been reports describing the detachment of the anterior leaflet chords and elongating them with artificial gortex neochordae to eliminate the SAM. I am sure this can be done but there is a more consistent solution. With SAM, MR and septal hypertrophy, I believe that detaching the anterior leaflet and extending the leaflet incision past the commisures, performing a septal myectomy and then suturing a pericardial patch to the defect in the anterior leaflet will resolve the problem. When performing the septal myectomy, I usually take a 3-0 silk needle and drive it into the thickened septum pull it down. Thereafter and 11 blade is used to incise the septum 3-4 mm from the aortic annulus. I will then use the long shafted metsenbaum scissor to complete an extensive myectomy. You can usually take more that you think. This approach will allow you to go deep into the septum towards the apex.

Over the years I have modified my technique for inserting the post for the atrial lift system.  Believe it or not,  patients were complaining about pain from this insertion site more than from the mini thoracotomy incision.

In the past I was making a small incision in the chest where I wanted to insert the post and thereafter passed a tonsil clamp from the incision and into the chest. I would then take a red rubber catheter , place it through the thoracotomy incision and pull it out through the small incision.  I would then use the red rubber catheter to guide the post back into the chest and later attach it to the blade.  I think that maybe the insertion of the clamp was just too traumatic.

Please view this short video to see the new technique that I strongly recommend.  I have provided the link below. (When you view it,  click on settings, which is the little pin wheel on the lower bar, third from the right.  This is the settings button. Click Quality and the select 720 HP. The resolution will be better)

If anyone has any suggestions or a better way, I would appreciate any comments.

I have enclosed a link for a comprehensive video on a Minimally Invasive approach to treat both ischemic and non-ischemic mitral regurgitation.These patients usually have poor EF’s. dilated LV with an inter papillary muscle distance greater than 2.5cm.

Femoral cannulation is preferred unless there is significant PVD and therefore axillary cannulation would be performed.  This technique is performed via a 5-6cm right mini-thoracotomy incision.  Aortic cross clamping is performed directly through the incision. I have been using Del Nido cardioplegia on a more frequent basis and delivering repeat doses every 45-55 minutes.

After the heart is arrested and an the atriotomy is performed, I place an atrial lift device and a Visor to provide additional visibility.  Once I have decided to place the papillary muscle SLING, I will use a mitral collar to provide further visibility of the the infra valvular structures. I then utilize a long curved clamp or a specialized curved instrument (developed by Raul Martinez, Nurse in charge of our Cardiac Team) to encircle the papillary muscles. (It is very rare not to be able to encircle the papillary muscles. I have recently encountered one case that had the papillary muscles completed fused to the ventricular wall.)  It is important to use a 4mm Gortex graft and to place the graft around the trabecula to avoid it from slipping and choking the chordae.  Once the graft is completely around the papillary muscles, I utilize a 4-0 proline to approximate the ends of the graft together. The graft needs to be relatively tight. A reference that I use is to place a yankour suction between the approximated papillary muscles.  You should not be able to softly push the suction between the papillary muscles.  If so, it needs to be tightened further.  Once the SLING is in place, I then place the annular sutures.  I never down size the annuloplasty ring in these cases.  I will size the ring to the exact size of the anterior leaflet.

I truly believe that this is a very good solution to a very difficult problem.  Our short and mid term results have been very good.

Stay blogged and I will soon post our data on over 35 cases.

http://youtu.be/wOfEz8d71jg

I have posted a 5 minute video of a minimally invasive MVRepair utilizing a folding-plasty.  I truly believe that we need a “toolbox” of techniques to be able to repair valves.  Not all valves are created equally.  I personally perform 600 minimally invasive valve procedures a year and half of these are mitral valve operations. I can truly say that there is NOT one universal way to repair all valves because all valves are not created equally.  In addition, not all valves can be, or should be repaired.  The technique in this video demonstrates an alternative to a triangular or quadrangular resection of P2. The prolapsed P2 segment is inverted and the rolled edges are approximated. It is important to have primary chordae on either side of the rolled edges.  At times, when the leaflet appears very redundant, I have also added one chordae and usually anchor it to the PM papillary muscle.