Quadrangular resection is the standard reconstruction technique for posterior leaflet prolapse, but when the posterior leaflet is excessively high, additional surgical methods are required to reduce the risk for systolic anterior motion (SAM).1–3 Butterfly resection has been developed as a repair technique that reduces the risk for SAM.3 It combines two triangular resections and allows precisely adjusted height reduction without annular plication. Because resection is a time-consuming procedure, we have developed an alternative “no resection” technique (reverse T-plasty). This technique is inspired by butterfly resection, but, as opposed to the butterfly resection, it contains foldings instead of resections.
Reverse T-plasty is a combination of mediolateral and anteroposterior plane foldings. To perform this procedure, the width of the free edge of prolapsed segment must be less than or equal to one third of the width of the corresponding annulus. First, by holding a gauge next to the leaflet, an isosceles triangle with a base at the free edge of prolapsing segment and two equal sides of 15 mm in length is marked on the posterior leaflet. A second triangle that shares the same apex with the first triangle and has its base at the annulus is also marked (Fig. 1, A0 and A1). After marking, a mediolateral plane folding is performed between two intact primary chordae adjacent to the prolapsing segment at the free margin by using 4-0 or 5-0 polypropylene sutures. The sides of the second triangle are then approximated to the annulus and sutured with 4-0 or 5-0 polypropylene sutures to carry out an anteroposterior plane folding (Fig. 1, A2 and A3). The final appearance of the sutures looks like a “reverse T” (Fig. 1, A4). Annular plication is not necessary, and the procedure is completed by ring annuloplasty using a rigid or flexible ring sized in accordance with the true size of the anterior leaflet. In patients in whom the width of the free edge of the prolapsed segment is more than one third of the width of the corresponding annulus, a limited triangular resection at the free edge must be performed first to remove the excessive tissue. After that, the same steps as those in reverse T-plasty are applied to perform a modified reverse T-plasty (Figs. 2, 3).
The reverse T-plasty technique was used in four symptomatic patients with severe mitral regurgitation (MR), and the modified reverse T-plasty was used in two patients. In these six patients, the mean (SD) cross-clamp and cardiopulmonary bypass (CPB) times were found to be 44 (8) minutes and 78 (13) minutes, respectively. Suitable (#33 and #34) rigid or flexible rings were used in all patients. Postbypass transesophageal echocardiography revealed no MR in one patient and trivial MR in five patients. The median follow-up duration is 8 months, and all patients are good in health at follow-up.
In reverse T-plasty technique, a good surface of leaflet coaptation is restored without resection, SAM is avoided, and cross-clamp and CPB times are shortened.
In a study of 53 patients comparing butterfly resection with quadrangular resection, butterfly resection provided significantly larger anterior-posterior leaflet ratio, greater length from the coaptation point to the septum, and implantation of larger prosthetic annuloplasty rings.4 In this study, the mean (SD) cross-clamp and CPB times of the butterfly resection group were reported as 79 (19) minutes and 115 (26) minutes, respectively. In our clinical experience, the mean (SD) cross-clamp and CPB times were found to be 44 (8) minutes and 78 (13) minutes, respectively. We propose that absence of any resection might be helpful to shorten the operative time, to eliminate the need for approximating sutures at a resected site, as well as to give opportunity of retrieving sutures and changing the repair method in the case of a failed first attempt. In this method, however, not performing a resection is also a disadvantage because it narrows the target patient population to a group of patients without excessive posterior leaflet tissue. In this patient group, modified reverse T-plasty technique with limited triangular resection is useful.
Folding plasty for posterior leaflet repair is a technique that reduces the height of the repaired leaflet, closes the gap created by leaflet resection by rotation of residual leaflet, and reduces the need for localized annular plication. Although there is some concern about excess tension to closing sutures, in a study of 531 patients, folding plasty is found to be durable at 10-year follow-up.5 Our technique combines mediolateral and anteroposterior foldings. Although we do know only short-term durability of our technique, favorable long-term results of folding plasty are encouraging.
Minimally invasive approaches to mitral valve repair have comparable short- and long-term results with traditional sternotomy, with potential for shorter hospital stay and less blood loss.6 Although we used midline sternotomy in all patients, we suggest that (modified) reverse T-plasty technique could also be performed using minimally invasive approaches.
In recent years, “respect rather than resect” strategy emerged, and artificial chordae became widely used as an alternative to the classic repair techniques. Reverse T-plasty is another “respect” strategy that does not require any resection. Although the use of polytetrafluoroethylene loops without resection or with limited resection is now the preferred technique in our center, we suppose that, in mitral valve surgery, it is certainly of interest to have a variety of different techniques ready to manage the various presentations of valve problems.
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