Practice English Speaking&Listening with: Mitral Valve Repair of Fibroelastic Deficiency

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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 patients 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.

The Description of Mitral Valve Repair of Fibroelastic Deficiency