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Mitral valve replacement with mechanical or bioprosthetic valve

David Wheatley*, Malcolm Will Department of Cardiac Surgery, Level 4, Queen Elizabeth Building, 10 Alexandra Parade, Glasgow Royal Infirmary, Glasgow G31 2ER, UK A presentation on the technique of mitral valve replacement is shown: exposure and excision of the diseased mitral valve is demonstrated along with the use of sub-annular and supraannular interrupted suture techniques for securing biological and mechanical mitral prostheses. A brief overview of the literature is presented.

Keywords: Mitral valve disease; Mitral valve replacement; Bioprosthesis; Mechanical valve Introduction
The first successful prosthetic mitral valve replacement was achieved by Nina Braunwald at the National Institute of Health in 1960 w1x. A year later, Albert Starr and Lowell Edwards published their results for what was to become the first commercially available prosthesis the Starr-Edwards ball and cage mitral valve w2x. This was the gold standard until the Bjork-Shiley tilting disk valve (1969) and then the St. Jude Medical bi-leaflet valve (1977) emerged onto the market. These second and third generation valves had superior haemodynamic profiles and fewer valve related adverse events. Alongside the development of mechanical prosthetic mitral valves, improvements in fixation techniques using gluteraldehyde (1968) led to the development of the Hancock and Carpentier-Edwards porcine bioprosthetic mitral valves. These valves proved to be popular but by the early 1980s structural valve deterioration, particularly in younger patients became an increasingly recognised complication. Improved tissue fixation techniques and use of bovine pericardial leaflets have improved the longevity of bioprosthetic mitral valves, although their use in the mitral position * Corresponding author: Tel.: q44-141 211 4730; fax: q44-141 552 0987. E-mail: d.j.wheatley@clinmed.gla.ac.uk
2005 European Association for Cardio-thoracic Surgery

is usually limited to the elderly or those with specific contra-indications to anticoagulation. Unstented mitral heterograft or allograft valves have the theoretical attraction of truly mimicking the natural mitral valve but at present they cannot be widely recommended.

Indications for mitral valve replacement and choice of prosthesis

Indications for mitral valve replacement take account of symptomatic status, occurrence of thromboembolic episodes or endocarditis, deterioration in pulmonary haemodynamics and myocardial function. Mitral valve replacement is not as satisfactory as a good repair procedure and the possibly of a repair should be carefully considered before recommending replacement. Recommendations for the management of valvular heart disease and the use of different valve prostheses are based on the guidance document from the American College of Cardiology/American Heart Association taskforce w3x1. Patient age, co-morbidity, the risks of valve related mortality, morbidity and reoperation must always be given full evaluation by the patient and surgeon when selecting a cardiac valve substitute.


D. Wheatley & M. Will / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2004.001024 thetic valve function following replacement, and it aids in the de-airing process w4x, (Video 1). Vertical sternotomy is the commonest and generally recommended approach to the heart. It gives optimal access to the aorta, allows other concomitant procedures to be undertaken readily, and allows de-airing and defibrillation to be undertaken in a way that is familiar to all surgeons. This approach may give a restricted view of the mitral valve since the left atrium is located posteriorly and the mitral valve is best viewed from the back of the heart (hence the good view obtained by transoesophageal echocardiography!). A right thoracotomy approach often gives a better view of the mitral valve, but poor access to the aorta and the left ventricle may create difficulties with cannulation, de-airing and defibrillation. When closed mitral valvotomy performed through a left thoracotomy gives an unsatisfactory result necessitating immediate progression to mitral valve replacement, this can be achieved through the same left lateral approach, albeit with less satisfactory views of the mitral valve. Cannulation for cardiopulmonary bypass should be undertaken before any manipulation of the heart to avoid cardiovascular instability and the risk of dislodging atrial thrombus (Video 2). To aid access to the left atrium it is advisable to place separate venous cannulae into the superior and inferior vena cavae. These should not cross within the right atrium inserting the inferior cannula close to the inferior vena cava aids exposure of the left atrium by the atrial retractor. Caval snares ensure good venous drainage. Our institution uses the Sarns aortic and venous return catheters (MMCTSLink 20) (Video 3). Cardiopulmonary bypass is established with moderate hypothermia (328). Following cross clamping of the ascending aorta, cold blood cardioplegia is delivered via a Medicut cannula in the aorta (MMCTSLink 21). The left atrium should be opened (by short incision close to the right superior pulmonary vein) immediately upon commencement of cardioplegic administration to avoid left heart distension in the event of mild aortic regurgitation being present, and to remove the warm blood present in the left atrium (thus aiding cooling of the heart). Care is needed to avoid return of topical cold saline via cardiotomy suction (Video 3). The left atriotomy incision is made close to the heart (just behind the inter-atrial groove) best commenced at the junction of the right superior pulmonary vein with the left atrium (this incision continues the opening already made for atrial decompression during cardioplegic arrest). The incision is extended superiorly

Video 1. Anaesthesia and monitoring, operative setup and approach to the heart are standard as for any major heart surgery. Transoesophageal echocardiography is a valuable adjunct. The surgical approach is most commonly by vertical sternotomy. Following heparinisation purse-string sutures are placed for cannulation.

Video 2. Arterial cannulation for cardiopulmonary bypass. This is done at an early stage and passing a tape around the aorta can be performed later when cardiopulmonary bypass is established. The aim is to commence cardiopulmonary bypass before the heart is handled or displaced in anyway.

Video 3. Avoiding crossing of the venous cannulae within the right atrium aids exposure of the left atrium and snares ensure good venous drainage. With the aortic cross clamp applied, cold blood cardioplegia is delivered into the aortic root and topical cold saline helps to cool the heart.

Surgical technique
Anaesthetic technique and monitoring of cardiovascular and respiratory systems are the same as for any major cardio-pulmonary procedure. Transoesophageal echocardiography has become an important adjunct to mitral valve surgery. It has a well recognised role in guiding mitral repair procedures and assessing their effectiveness, but in the setting of mitral valve replacement it is helpful in confirming unsuitability for a repair procedure (calcific masses or severe chordal fusion), it will confirm normal pros2

D. Wheatley & M. Will / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2004.001024 toward the left atrial roof, and inferiorly in front of the inferior pulmonary vein and behind the inferior vena cava w5x (Video 4). Other approaches to the mitral valve are described and include the superior approach through the atrial roof, and the transeptal approach in which the right atrium is opened by vertical incision, which extends into the inter-atrial septum w6x.
Video 4. The left atrium is seen behind the inter-atrial groove displaying the site for atriotomy. A stab incision here allows early decompression of the heart and pulmonary circulation and also aids in cooling of the heart by removing warm blood within the left atrium.

The mitral valve can be exposed using the self-retaining Cosgrove retractor MMCTSLink 22 (which has the advantage of creating a good, stable operating field while freeing the surgical assistant), or using a hand-held atrial retractor such as the Cooley retractor MMCTSLink 23 (which allows the assistant to adjust the view as appropriate). Grasping the posterior leaflet and pushing it posteriorly can improve the view of the mitral valve (Video 5). Excessive traction on the valve should be avoided particularly keeping in mind the risk of overstretching and rupturing the adjacent posterior left ventricular wall.

Video 5. With cardiopulmonary bypass established, via left atriotomy exposure of mitral valve is aided by posterior displacement of valve. Excessive traction on the valve annulus should be avoided; rupture of the posterior left ventricular wall is a known hazard.

The first consideration must be to confirm that a repair procedure is not feasible. Resection of the valve commences close to the junction of the anterior leaflet with the atrial floor, leaving a rim of 23 mm of atrial tissue. This gives an edge suitable for grasping in a Roberts forceps and allows the valve to be displaced as necessary for a view of the resection line around the leaflet base, as well as a view of the subvalvular mechanism (Video 5). An important consideration is the extent to which mitralannular continuity can be preserved w7x. Although it may be possible to preserve all chordae, the commonest chordal preservation is by leaving as much of the posterior leaflet in place as is feasible. Large calcified masses of fused chordae often need to be resected simply to give enough space for the prosthesis. Excess tissue may need resection. The rim of retained leaflet tissue should be minimal and loose chordae, which may interfere with a mechanical valve, should be resected. Resection of chordae should be just above their insertion into the papillary muscle, avoiding transection of the papillary muscle itself (Video 6). Each valve prosthesis manufacturer provides sizers that aid in selection of the appropriate prosthesis size the commonest sizes being 29 mm or 31 mm (Video 7). Selection of type of prosthesis should have been made in consultation with the patient, taking account of the need for continuing valve-related therapy. In the 3

Video 6. Excision of the anterior leaflet of mitral valve with division of chordae. Avoid leaving free chordae that may interfere with valve closure. Where possible, the posterior leaflet with its chordal attachments should be preserved.

Video 7. Excised valve. Trimming excess tissue. Sizing of mitral annulus. Avoid disrupting calcific material fragments may fall into the pulmonary veins or left ventricle. The manufacturers sizers aid in the selection of the appropriate prosthesis size.

D. Wheatley & M. Will / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2004.001024 mechanical prostheses unless strong contra-indications to anticoagulation exist. Several effective techniques are advocated for anchoring the prosthesis. When access is good, and annular tissues are tough and fibrous, a continuous running suture technique has the advantage of speed w8x. This technique should only be used when the surgeon is confident of its ease and security. Placement of interrupted sutures with pledgets is more consistently reliable, particularly with restricted access and friable tissues. A double-ended 2/0 pledgetted suture with large needles (26 mm) is ideal. Ethibond (MMCTSLink 24) and Ticron (MMCTSLink 25) sutures are conveniently supplied in alternate colours to aid identification for tying. For implantation of a mechanical valve the pledgets are positioned on the atrial floor and the sutures emerge just below the annulus at the junction of fibrous tissue with myocardium. The sutures should be inserted 35 mm from the annulus and should emerge within fibrous tissue and not from myocardium. The distance between the two points of emergence of the double-ended suture should be about 68 mm and the next double-ended suture should start close by (12 mm). In practice, some 1518 double-ended sutures are required. Excessive suture depth in the posterior-superior aspect of the annulus may damage the circumflex artery, and in the anteriorsuperior annulus misplaced sutures may injure the aortic valve (Videos 8 and 9). Suture placement for a bioprosthetic valve should be with the pledgets on the ventricular aspect of the mitral annulus and the sutures emerging on the atrial floor, with spacing and suture type as for a mechanical prosthesis. Care should be taken to keep the bioprosthesis moist with normal saline. With any stented bioprosthesis there is a serious risk of entrapment in the sutures of one or more stent posts. This risk is much reduced if the valve has a protective suture in place linking the post tips (such has that provided by the Carpentier-Edwards porcine mitral valve (MMCTSLink 26) this should not be removed until the valve has been securely placed in position. If the manufacturer does not provide this protective mechanism, care should be taken to position each post through the mitral valve annulus, with a good view, and with the sutures under tension in order to confirm that there is no post entrapment (Videos 10 and 11). Before placing sutures through the prosthesis sewing ring the valve should be orientated in its intended position (this simplifies or even obviates the need for subsequent adjustment). Once in place most mechan-

Video 8. Placement of the first sutures in the mitral annulus. Unless the annulus is very fibrosed and tough, interrupted sutures with pledgets are the most reliable for securing the valve.

Video 9. Sutures are placed around the annulus, using traction on neighbouring sutures to aid exposure of the annulus for the next suture.

Video 10. Suture placement for a bioprosthetic valve should be with the pledgets on the ventricular aspect of the mitral annulus and the sutures emerging on the atrial floor.

Video 11. A bioprosthetic valve being inserted into the mitral annulus. The valve posts should not obstruct the left ventricular outflow tract, so aim to locate the posts close to each trigone.

case of mitral valve replacement the onset of atrial fibrillation is so common in the natural history that many centres would advocate universal use of 4

D. Wheatley & M. Will / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2004.001024

Video 12. Sutures being passed through the prosthetic valve sewing ring. Spacing corresponds to gaps between the sutures on the atrial floor.

Video 16. Atrial closure nears completion; valve splinting catheter in place. At this stage, the lungs are ventilated by the anaesthetist to encourage left atrial return and help with de-airing.

Video 13. Valve seated, orientation checked, holder removed, unimpeded leaflet movement confirmed and accuracy of seating confirmed.

valve and similarly disc motion should not be confirmed by touching the leaflet with a surgical instrument the manufacturers valve testing probe should be used. Single disc valves are orientated with the disc mimicking the anterior leaflet i.e. the greater opening is posteriorly placed. Bileaflet valves are orientated with the axis of opening in line with the middle of the aortic root. Local anatomy may modify the desired orientation e.g. an unresected mass of calcium may risk disc impingement in certain valve orientations. Bioprosthetic valves are orientated with two posts at trigones i.e. one leaflet attachment is positioned along the sub-aortic curtain, ensuring that a post does not intrude into the left ventricular outflow tract. Spacing of the sutures in the sewing ring should match that of the spacing in the annulus. Most sewing rings have markers to aid judgement commonly allowing the sutures to be separated into 3 or 4 groups. Sutures can be held in groups by an assistant, fastened to the wound towels, or held in a purposemade retaining device. Alternate colour sutures, or a single hitch knot made in each suture, are additional ways of avoiding suture entanglement, and simplifying identification for rapid tying. Generally, a minimum of 6 knots are recommended, with the first two being slip knots to aid in tightening (Videos 12, 13 and 14). Our practice is to leave the left atrial appendage alone unless there is visible thrombus within it, in which case we would place a purse string suture from within the left atrium to occlude the appendage w9,10x. With mechanical valves, placement of a small Foley catheter (14F) across the valve with inflation of the balloon in the ventricle prevents full valve closure and is an aid to venting and de-airing. The balloon must be fully deflated prior to removal (Video 15). The left atriotomy is closed with a running monofilament suture (we use 3/0 Prolene - MMCTSLink 27), commencing a suture at each end of the atriotomy 5

Video 14. Tying of sutures is commenced. First two sutures are thrown as slipknots to ensure tightening and then square knots are used for a total of six knots.

Video 15. Temporary valve splinting with a soft catheter allows left ventricle to decompress into the atrium. Closure of the atriotomy is commenced.

ical valves can be rotated to optimise orientation but this should only be done using the manufacturers purpose-made device. Attempting to twist valves with surgical instruments carries a risk of damaging the

D. Wheatley & M. Will / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2004.001024 from 1.5% to 2.0% per patient-year. This relates to the higher target INR (International Normalized Ratio). The incidence of perivalvular leak ranges from 0% to 1.5% per patient-year. The type of prosthesis used does not influence the incidence of prosthetic mitral valve endocarditis incidence -1% per patient year in most series.

Video 17. Reperfusion of the heart following de-airing is followed by spontaneous return of coordinated ventricular contractions. Transoesophageal echocardiography often reveals small left atrial bubbles, encouraging diligence in de-airing. The catheter balloon is deflated and the catheter removed enabling completion of the atriotomy. A needle vent in the ascending aorta will scavenge any residual air.

w1x Braunwald NS, Cooper T, Morrow AG. Complete replacement of the mitral valve. Successful clinical application of a flexible polyurethane prosthesis. J Thorac Cardiovasc Surg 1960;40: 111. w2x Starr A, Edwards ML. Mitral replacement: clinical experience with a ball-valve prosthesis. Ann Surg 1961;154:726740. w3x Bonow RO, Carabello B, de Leon AC, Edmunds LH Jr, Fedderly BJ, Freed MD, Gaasch WH, McKay CR, Nishimura RA, OGara PT, ORourke RA, Rahimtoola SH, Ritchie JL, Cheitlin MD, Eagle KA, Gardner TJ, Garson A Jr, Gibbons RJ, Russell RO, Ryan TJ, Smith SC Jr. Guidelines for the management of patients with valvular heart disease: executive summary. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Patients With Valvular Heart Disease). Circulation 1998; 98:19491984. w4x Click RL, Abel MD, Schaff HV. Intraoperative transesophageal echocardiography: 5-year prospective review of impact on surgical management. Mayo Clin Proc 2000;75:241247. w5x Larbalestier RI, Chard RB, Cohn LH. Optimal approach to the mitral valve: dissection of the interatrial groove. Ann Thorac Surg 1992; 54:11861188. w6x Utley JR, Leyland SA, Nguyenduy T. Comparison of outcomes with three atrial incisions for mitral valve operations. Right lateral, superior septal, and transseptal. J Thorac Cardiovasc Surg 1995;109:582587. w7x Reardon MJ, David TE. Mitral valve replacement with preservation of the subvalvular apparatus. Curr Opin Cardiol 1999;14:104110. w8x Cooley DA. Simplified techniques of valve replacement. J Card Surg 1992;7:357362.

and ending anterior to the right superior pulmonary vein the high point of the left atrium and a suitable site for evacuation of air (Videos 16). Once de-airing is complete the aortic cross-clamp is released. When regular left ventricular contractions are established (if necessary, by defibrillation) the Foley catheter balloon is deflated, the catheter is extracted and the atriotomy suture line is completed. A Sarns aortic needle vent catheter (MMCTSLink 28) is placed in the ascending aorta for several minutes to scavenge any residual air (Videos 16 and 17). Discontinuation of cardiopulmonary bypass, haemostasis and chest wall closure follow.

Short and long-term outcomes following mitral valve replacement are summarised below w1114x: Early mortality after elective mitral valve replacement is approximately 5% in most series. The ten-year survival following mitral valve replacement is around 5060%. The incidence of structural valve deterioration is virtually zero for mechanical mitral valves. However, for bioprosthetic mitral valves structural degeneration typically affects 2040% patients at 10 years and over 60% at 15 years. Therefore, most surgeons do not recommend using these valves routinely in patients under 65 years of age. The incidence of major thromboembolism including valve thrombosis ranges from 1.5% to 2.5% per patient-year. The incidence of haemorrhage is higher in those patients with a mechanical prosthesis and ranges 6

D. Wheatley & M. Will / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2004.001024 w9x Garcia-Fernandez MA, Perez-David E, Quiles J, Peralta J, Garcia-Rojas I, Bermejo J, Moreno M, Silva J. Role of left atrial appendage obliteration in stroke reduction in patients with mitral valve prosthesis: a transesophageal echocardiographic study. wSee Commentx. J Am Coll Cardiol 2003;42:12531258. w10x Stollberger C, Schneider B, Finsterer J. Elimination of the left atrial appendage to prevent stroke or embolism? Anatomic, physiologic, and pathophysiologic considerations. Chest 2003; 124:23562362. w11x Hammermeister K, Sethi, GK, Henderson WG, Grover FL, Oprian C, Rahimtoola SH. Outcomes 15 years after valve replacement with a mechanical versus a bioprosthetic valve: final report of the veterans affairs randomized trial. J Am Coll Cardiol 2000;36:11521158. w12x Oxenham H, Bloomfield P, Wheatley DJ, Lee RJ, Cunningham, J, Prescott RJ, Miller HC. Twenty year comparison of a Bjork-Shiley mechanical heart valve with porcine bioprostheses. Heart 2003;89:715721. w13x Grunkemeier GL, Li HH, Naftel DC, Starr A, Rahimtoola SH. Long-term performance of heart valve prostheses. Curr Probl Cardiol 2000;25: 73154. w14x Jamieson WR. Choice of cardiac valve substitutes. In: Treasure T, Keogh B, Hunt I, Pagano D, editors. The evidence for cardiothoracic surgery. UK: tfm Publishing Ltd; 2004:201220.