Dr. David H. Adams: This echo shows the mitral valve of a 50 year old physician
with posterior leaflet prolapse
and a moderate jet of insufficiency
which is demonstrated by the red color
backwards into the atrium.
We are now using hooks to perform a valve analysis.
When we put saline in,
you see the central leak of water out of the ventricle
as the two leaflets do not meet.
The forceps are grabbing the posterior leaflet
and the hook shows the elongation
of the chordae or strings
that results in the prolapse.
The first step of a valve repair
is to mark the supporting strings or chordae
that you are going to preserve.
As is obvious here, the segment that prolapses
often becomes distended like a sail from pressure.
So the goal of the valve reconstruction
is to perform, literally,
a plastic surgery operation on the leaflets
to remove the excess tissue.
We have now used the blue strings or Prolene
to mark the margins of resection
and what you see is the indentation between
the different scallops or segments of the leaflets.
Notice the normal height
sometimes can be as short as 5 mm to a centimeter
and that the distended leaflet segment
is over 2 cm tall.
Now we are performing a partial resection
of the distended segment.
Part of the judgement of valve reconstruction
is not resecting too much tissue
because we need to use the patient’s own leaflet
to reconstruct the normal coapting surface.
So in this case, I have elected not
to resect the entire leaflet
but only half of the prolapsing segment.
As you can see, there are now good chords
marked by the blue strings
from the retained leaflet tissue.
In order to shape the posterior leaflet
we are going to detach part of it
from the supporting structure
of the valve which is called the mitral annulus.
This will allow us to perform a small resection
at its base as you can see,
which will allow the overall leaflet height to be adjusted
so that it matches the residual segments
that were not cut.
This is a very important part of tailoring
a mitral valve repair
to create a normal coaptation surface.
I am now measuring or comparing the two leaflets
to make sure the residual height will be equal.
The height of the segment adjacent to the cut segment
is also tall so I am using a knife
to divide it from the annulus
and will similarly cut a small piece of tissue.
Watching the operation demonstrates the numerous times
judgement is required in performing these
plastic surgical operations on the leaflets.
Of course, each valve is different
and each valve requires a different
thought process and different incisions.
Before we reconstruct the leaflet
we take advantage of the gap created by the resection
to place this series of green and white sutures.
These sutures will later be used
to perform an annuloplasty.
An annuloplasty involves tying a ring
around the valve to support its normal shape.
After placing the annuloplasty sutures
we now use a small thread of Prolene
to reattach the leaflet to the annulus.
So bites are taken through the edge of the leaflet
and then through the frame of the valve
reattaching it not only in the correct position
but with good chordae
now supporting its free margin.
All of these steps require great precision
because the interventricular pressure is quite high.
The pressure on the repair will really point out
even minor imperfections so the surgeon
takes a great deal of time aligning the leaflet
back up so that it will have a normal shape and size.
We are now going to perform a similar maneuver
on the adjacent leaflet segment
reattaching it to the frame of the valve.
As this case shows it is not always
a symmetric cut or displacement
as we have performed what is called a sliding plasty
much more aggressively toward
the medial side of the valve
in order to come up with a symmetric shape.
The next step of a valve repair
is to put the two cut edges
of the residual leaflet back together.
We employ additional small sutures
to reconstruct the leaflet edges.
Several sutures are used
to reconstitute the valve surface.
Now you can see the reconstructed posterior leaflet
and the uniformity of height of the residual segments.
The leaflet is all now well supported
by the residual chords at the margin.
We now will place the remainder
of the ring sutures in the annulus
which is the supporting frame around the valve.
We prefer rings that are complete so it requires
placement of sutures along the top of the valve.
The advantage of such rings
is that they have a greater remodeling effect
or reshaping effect
than a posterior band annuloplasty.
In this area of the valve extra care must be taken
because the aortic valve is just behind
the mitral valve in close proximity.
As you can see, we have sizers that we match
to the surface area of the anterior leaflet
and that helps us pick a ring
that will correspond to the size of the valve.
Now the sutures are used to implant the ring
and you can see the final repair now.
We fill the ventricle with saline
and now the valve is completely competent,
holding water in the ventricle under great pressure.
In a test we designed at Mount Sinai,
we now draw a line on the valve with ink
which allows us to then assess
the amount of leaflet coapting inside the ventricle.
As you can see, now several millimeters of the valve,
almost a centimeter in the area we resected
is all available for coaptation or sealing.
The postoperative echo now shows
a normal valve motion with a long line of coaptation
and no evidence of mitral regurgitation.
