Annular ring dehiscence is a well-described complication of mitral valve repair.1–7 Patients with ring dehiscence usually present in a delayed fashion with heart failure symptoms. In ischemic mitral regurgitation, in which downsizing of the annulus is important, there is usually greater stress on the ring or band attachments especially in areas with weak or calcified annular tissue, which increases the risk for annular tears and ring dehiscence.5 Such dehiscence may be as extreme as complete detachment of the ring with migration into the descending thoracic aorta.4 Ring dehiscence can often be seen by three-dimensional transesophageal echocardiography.3 Pledgeted mattress sutures have been described as providing improved prosthetic valve stability during mitral valve replacement.8 We apply the same techniques for mitral valve repair. Herein, we describe a technique for mitral annuloplasty using pledgeted sutures.
Exposure and assessment of the mitral valve proceed as described elsewhere.9 When a ring or band is chosen as part of the mitral valve repair procedure, pledgeted sutures are placed in an everting fashion through the mitral annulus as shown in Figure 1. The needle enters the left atrium and exits at the annular hinge in a supra-annular fashion. The double-armed pledgeted annuloplasty sutures are spaced at the appropriate distance so as to allow some cinching of the annulus (Fig. 2). Sutures are then placed through the annuloplasty band or ring and tied (Fig. 3). Care should be taken during suture placement to avoid injury to the circumflex coronary artery as shown in Figure 1. It is important for the needle to exit at the hinge of the annulus, and not through the valve leaflet, to avoid leaflet tearing.
When performing mitral annuloplasty procedures with a mitral ring or partial band, surgeons routinely use a technique of simple suture placement without pledgets, parallel to the annulus. In some cases, especially when a significant reduction of the annulus is achieved such as in patients with ischemic mitral regurgitation, significant radial force may be applied by the ring to reduce the size of the annulus, with the resulting risk of suture tearing and ring dehiscence. The main advantage of using the technique described in this article is the increased strength of the pledgeted sutures placed radially and circumferentially around the annulus, possibly resulting in increased stability of the mitral ring or band. Using supra-annular pledgeted sutures as described adds minimal time to the repair procedure. Similar to the supra-annular placement of sutures in mitral valve replacement, the risk for injuring the circumflex artery persists, as shown in Figure 1. However, this risk is equal to or less than that in valve replacement because, in mitral repair, the pledgeted sutures exit at the valve hinge and not below it (Fig. 1). Another potential disadvantage is that, should adequate mitral competency not be achieved by the annuloplasty procedure, the ring would have to be removed and all pledgets would have to be carefully retrieved. This is, however, not difficult because the pledgets are placed above the annulus. In summary, it is unknown whether this technique of using supra-annular pledgeted sutures in the setting of mitral annuloplasty results in a reduced risk for mitral ring or band dehiscence. However, the added strength of pledgeted sutures as determined by others8 may theoretically reduce such risk.
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