Residual Mitral Regurgitation After Mitral Valve Repair: Leaflet Perforation

By: Mitral Foundation

In our Mitral Foundation Video Teaching Library we are going to show a series of cases that demonstrate teaching points in the field of Mitral Valve Reconstruction. In this video, we're going to discuss the problem of residual mitral valve regurgitation after mitral valve repair. Specifically, focusing on two different examples of leaflet perforation and how to deal with them. These are our disclosures. The first example of leaflet perforation that we're going to discuss is the central leak between the edges of two leaflets that are brought back together and repaired. This can occur after triangular resection or quadrangular resection, and we've seen it both with running suture, as well as with interrupted sutures. This can come from loose suture or from leaflet tearing, and it's a very important problem to address. The case we're doing today is a 58 year old man who's been under watchful waiting for asymptomatic mitral valve regurgitation for several years.

He has a ruptured chord and flailed segment of his posterior leaflet. And his latest transthoracic echo shows severe mitral valve regurgitation, with decreasing left ventricular ejection fraction resulting in his referral for surgery. Here on the echo, you can see an anteriorly directed jet from posterior leaflet prolapse in the p 2 segment, which is also obvious on the 3-dimensional en face view. He underwent a standard repair for this lesion including a triangular resection as well as implantation of a true-sized band. And I'm showing you the closure line at the end, with the ventrical full of saline, no residual leak. As you'll see from this echo, we had a small mild leak centrally inside the orifice of the valve inside the band after we came off the heart lung machine. This is a mild leak, you could elect not to explore it.

In a young, healthy and otherwise asymptomatic patient doing well from a ventricular standpoint, we usually will take a second look on the heart lung machine which is what we decided to do in him. And here you can see the pathology we identified. With our hook we found a gap between the two edges of leaflets. We can reconstruct it with Prolene suture. Obviously, these gaps are simple to fix with the, an interrupted suture.

And here's the final echo now with no residual valve regurgitation. The take home there again is a central leak after standard leaflet repair you should think about leaflet perforation as a possibility and in general, it's a very simple thing to address. The second example of leaflet perforation I'd like to review involves a tear at the hinge point of the valve. This is not an uncommon lesion, particularly around the anterior commissural area.

Residual Mitral Regurgitation After Mitral Valve Repair: Leaflet Perforation

And what you'll see is a small leak, usually on the inside of the ring. Usually that comes from a suture that has perforated the leaflet, as opposed to the hinge point of the annulus. The case we're gonna show you is an 81 year old woman in cronic atrial fibrillation with type one regurgitation, she has mild mitral annular calcification and was referred for surgical repair. Here's the preoperative echocardiogram showing a type 1 dysfunction with a centrally directed leak of mitral valvular regurgitation. Here's the completed repair that we did for this patient, she had a true-sized annuloplasty ring implanted and you see good coaptation and a completely normal saline test. And so obviously here we're very confident that we have executed a good repair, but it's very important again to carefully look at the echo cardiogram after surgery, because things can change between now, and then as I'll show you. Here's the post operative echo, and what you can see is again mild leak of mitral valve regurgitation at the base of the ring suggestive of a tear at the hinge point.

Again, this is the sort of leak if the patient's otherwise stable but we usually will re-explore often looking for a tear or perforation. Here is the saline test after we reopen the heart. And you can see this clear tear at the hinge point near the anterior commissure. The way we repair that is with a pledgeted, Prolene suture. We use a 5-0 suture and a piece of autologous pericardium. And you wanna tie that behind the ring, and here you can see the final repair. So whenever you see a perforation at the hinge point, the way that we'd repaired it is just how we showed.

And here you can see the post op echo now after repair with no residual leak. So in summary high velocity jets after mitral valve repair strongly suggest leaflet perforation. They're usually simple lesions to re-repair. And if patients are stable and have good ventricular function, it's usually worth a second look on bypass to identify them. They can be dynamic and they can also happen from a pressurized ventricle and when you see them, you shouldn't just trust the sailing test, you should go back on and reexamine the valve. I hope you found this video educational in your pursuit of excellence in mitral valve reconstruction.

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