I have performed a total of 35 minimally invasive MVRepairs with an anterior leaflet augmentation for multiple different pathologies including rheumatic disease. severe MAC, radiation valvulopathy, and severe SAM with IHHS.

33 have been with bovine pericardium, 1 with untreated autologous pericardium and 1 with CardioCel.  I have not used CorMatrix because of the multiple reports claiming that on the left side of the heart, there can be a disruption of the patch.  I cannot personally attest to this since I have only used it once on a tricuspid valve reconstruction.

The last of the 35 cases that I performed an anterior leaflet augmentation was with CardioCel.  I found it very comfortable to work with.  It is very flexible and soft and it is easy to pass a 5-0 needle through it. A  saline test of the valve can be performed with this material as opposed to bovine pericardium which is very stiff and competency of the repair can only be assessed once the heart is beating.

I think this will be my go to patch for now and would like to eventually compare its results with the bovine pericardial cases. Of note, I have been told that all of the bovine pericardial patches will eventually calcify but I have not seen that yet since my follow up is not long enough.

I have enclosed pictures.  All of my cases have been performed via a right lateral mini thoracotomy. I truly believe that the visualization is superior to a sternotomy in addition to the fact that a more extensive and complete myectomy can be performed via the mitral valve.

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.

I have enclosed a link to a 14 minute video on an anterior leaflet augmentation performed via a minimally invasive approach.  I have used bovine pericardium in all but one case in which I used autologous, untreated pericardium.  I believe that this technique should be performed with bovine pericardium or glutaraldehyde treated pericardium.  There is a new product on the market called CardioCel which may also be promising. A recent paper presented at ISMICS in Boston by Dr. Guy demonstrated that there was a high incidence of patch complications utilizing Corematrix.

http://youtu.be/vrPhKUWAjz8

I will share with you some pics from a case I performed today. I have a short video that I edited from a previous case but wanted to get this out tonight.  This is a minimally invasive MVRepair in a patient that has Mitral Stenosis.  Most cases of Mitral Stenosis are treated with an MVReplacement. This is an alternative approach whereas anterior leaflet augmentation with bovine pericardium is utilized to enlarge the anterior leaflet.  It is extremely important to detach the anterior leaflet beyond the commisures and utilize a very large annuloplasty ring. If the commisures are fused (as in this case) a commisurotomy is performed as well as addressing the fused and fibrotic chordae. In this case a 40 mm 3-D profile rigid ring. I know many of you will criticize a rigid ring in a mitral stenosis case, but I have my own philosophy and will explain in a future blog.