Innovations: Technology & Techniques in Cardiothoracic & Vascular Surgery:
Abstract: Annuloplasty ring or band dehiscence is a possible complication of mitral valve repair surgery. It may be due to increased tension on the annuloplasty sutures, especially in ischemic mitral pathology in which a circumferential ring is used. Herein, we describe a technique for alternative suture placement in mitral annuloplasty using pledgeted sutures that may reduce the risk for ring or band dehiscence.
From the *Division of Cardiothoracic Surgery, and †Department of Anesthesiology, University of New Mexico Health Science Center, Albuquerque, NM USA; and ‡Department of Cardiothoracic Surgery, University of Miami/Jackson Memorial Hospital, Miami, FL USA.
Accepted for publication January 11, 2014.
Disclosure: The authors declare no conflicts of interest.
Address correspondence and reprint requests to Mohammed Hassan, MD, Division of Cardiothoracic Surgery, Department of Surgery, University of New Mexico Health Science Center, 2-ACC MSC10 5610, 1 University of New Mexico, Albuquerque, NM 87131-0001 USA. E-mail: email@example.com.
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.
1. Jassal D, Neilan TG, Fatima U, et al. Mitral valve ring dehiscence with an aorta-left atrial fistula. Eur J Echocardiogr. 2007; 8: 296–298.
2. Martin A, White J, Pemberton J. Severe mitral regurgitation secondary to dehiscence of a mitral annuloplasty ring shown on 3D transoesophageal echocardiography. Heart Lung Circ. 2012; 21: 194–195.
3. Iida R, Shanks M. Three-dimensional transesophageal echocardiography shows dehiscence of mitral valve repair. Tex Heart Inst J. 2012; 39: 772–773.
4. Tsang W, Wu G, Rozenberg D, Mosko J, Leong-Poi H. Early mitral annuloplasty ring dehiscence with migration to the descending aorta. J Am Coll Cardiol. 2009; 54: 1629.
5. Aggarwal G, Schlosshan D, Mathur G, Wolfenden H, Cranney G. Recurrent ischaemic mitral regurgitation post mitral annuloplasty due to suture dehiscence evaluated using real time three dimensional transoesophageal echocardiography. Heart Lung Circ. 2012; 21: 844–846.
6. Shapira AR, Stoddard MF, Dawn B. Images in cardiovascular medicine. Dehiscence of mitral annuloplasty ring. Circulation. 2005; 112: e305.
7. Levack M, Vergnat M, Cheung AT, Acker MA, Gorman RC, Gorman JH III. Annuloplasty ring dehiscence in ischemic mitral regurgitation. Ann Thorac Surg. 2012; 94: 2132.
8. Newton JR Jr, Glower DD, Davis JW, Rankin JS. Evaluation of suture techniques for mitral valve replacement. J Thorac Cardiovasc Surg. 1984; 88: 248–252.
9. Atluri P, Woo YJ, Goldstone AB, et al. Minimally invasive mitral valve surgery can be performed with optimal outcomes in the presence of left ventricular dysfunction. Ann Thorac Surg. 2013; 96: 1596–1601.