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Mitral measurement: All or nothing?

Published:October 22, 2022DOI:https://doi.org/10.1016/j.jtcvs.2022.09.040
      To the Editor:
      The author reported no conflicts of interest.
      The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest.
      The recent report of McCarthy and colleagues
      • McCarthy P.M.
      • Herborn J.
      • Kruse J.
      • Liu M.
      • Andrei A.C.
      • Thomas J.D.
      A multiparameter algorithm to guide repair of degenerative mitral regurgitation.
      highlights several important points. The authors have reminded us that the national surgical repair rate for regurgitant mitral valves of 82% is well below rates achieved in centers of excellence. They attribute this to the complexity of the mitral repair techniques described by Carpentier, who has advocated multiple variants of leaflet resection to treat prolapsing segments and correct “excessive leaflet size.” McCarthy and colleagues noted that the surgeons in these experienced centers speak of having had to master what they refer to as not only the science but also the “art” of mitral valve repair.
      • McCarthy P.M.
      • Herborn J.
      • Kruse J.
      • Liu M.
      • Andrei A.C.
      • Thomas J.D.
      A multiparameter algorithm to guide repair of degenerative mitral regurgitation.
      ,
      • Gillinov M.
      • Burns D.J.P.
      • Wierup P.
      The right WAYS to repair the mitral valve.
      McCarthy and colleagues
      • McCarthy P.M.
      • Herborn J.
      • Kruse J.
      • Liu M.
      • Andrei A.C.
      • Thomas J.D.
      A multiparameter algorithm to guide repair of degenerative mitral regurgitation.
      are to be commended for their insistence on development of a quantifiable and reproducible technique to replace the need for subjective judgment.
      My own experience with these techniques also led me to a reappraisal of the Carpentier approach. During the 1980s and 90s, advances in cardiac imaging revealed the adverse impact of these techniques on normal function of the “mitral complex”
      • Watanabe N.
      The mitral complex: divine perfection.
      and led to my complete abandonment of leaflet resection and rigid or semirigid D-shaped rings. A multidisciplinary imaging study group was formed to focus on the development of a repair technique to restore normal physiology to all elements of the mitral complex, as documented by transesophageal echocardiography, cardiac magnetic resonance imaging, engineering studies of motion and strain patterns, and clinical outcomes.
      The result was the “American correction” or “dynamic mitral repair.”
      • Lawrie G.
      • Zoghbi W.
      • Little S.
      • Shah D.
      • Earle N.
      • Earle E.
      One hundred percent repair of mitral prolapse: results of a dynamic nonresectional technique.
      Polytetrafluoroethylene neochordae were used to restore normal leaflet mobility. Fully flexible adjustable rings sized to encompass the entire circumference of the inflated mitral annulus, including the aortic–mitral membrane, were used to achieve optimal systolic and diastolic function and avoidance of left ventricular outflow tract obstruction. All alignments were made during pressurization of the mitral complex to the early isovolumic state.
      Because all elements of the mitral complex are inflated and properly aligned in their isovolumic systolic positions, and the zone of apposition is marked on the leaflets before any adjustments are made, no measurements of leaflets or annulus are needed. With precise positioning of leaflet and left ventricular outflow tract relationships, no leaflet resection is ever necessary. The technique allows for multiple points of testing by high-flow saline infusion from a mechanical irrigator. This allows accurate real-time checking and adjustment of neochordal length and annular ring physiological sizing and adjustment before unclamping. This has eliminated second pump runs. The same exact repair technique is used for all forms of degenerative disease.
      This approach is the opposite to that advocated by Perier and colleagues,
      • Perier P.
      • Hohenberger W.
      • Lakew F.
      • Batz G.
      • Urbanski P.
      • Zacher M.
      • et al.
      Towards a new paradigm for the reconstruction of posterior leaflet prolapse: midterm results of the “respect rather than resect” approach.
      who used neochordae to create “an immobile buttress” from the posterior leaflet during an otherwise-classical Carpentier repair. In no way does dynamic repair resemble “respect or resect.” For those seeking a highly reproducible repair technique based solely on science and not requiring any measurements or calculations, the “American correction”
      • Lawrie G.
      • Zoghbi W.
      • Little S.
      • Shah D.
      • Earle N.
      • Earle E.
      One hundred percent repair of mitral prolapse: results of a dynamic nonresectional technique.
      offers another option.

      References

        • McCarthy P.M.
        • Herborn J.
        • Kruse J.
        • Liu M.
        • Andrei A.C.
        • Thomas J.D.
        A multiparameter algorithm to guide repair of degenerative mitral regurgitation.
        J Thorac Cardiovasc Surg. 2022; 164: 867-876https://doi.org/10.1016/j.jtcvs.2020.09.129
        • Gillinov M.
        • Burns D.J.P.
        • Wierup P.
        The right WAYS to repair the mitral valve.
        Ann Thorac Surg. 2021; 112: 1921
        • Watanabe N.
        The mitral complex: divine perfection.
        Circ Cardiovasc Imaging. 2016; 9: 1-3
        • Lawrie G.
        • Zoghbi W.
        • Little S.
        • Shah D.
        • Earle N.
        • Earle E.
        One hundred percent repair of mitral prolapse: results of a dynamic nonresectional technique.
        Ann Thorac Surg. 2021; 112: 1921-1928
        • Perier P.
        • Hohenberger W.
        • Lakew F.
        • Batz G.
        • Urbanski P.
        • Zacher M.
        • et al.
        Towards a new paradigm for the reconstruction of posterior leaflet prolapse: midterm results of the “respect rather than resect” approach.
        Ann Thorac Surg. 2008; 86: 718-725

      Linked Article

      • Reply: Science and judgment in mitral repair: The proof is in the pudding
        The Journal of Thoracic and Cardiovascular Surgery
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          We appreciate the comments from Dr Lawrie, who pioneered the “American Correction.”1,2 We are aligned on the importance of standardizing mitral repair for the best immediate, and long-term, results. Like Dr Lawrie, we always use a complete remodeling ring; he chooses one that is fully flexible, and we use one that is semiflexible. We differ in the importance of chord preservation. More recent acute animal studies using sophisticated echo imaging, including strain analysis, show no difference in postoperative left ventricular function between leaflet resection and neochord replacement.
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