In Part I of this article, several aspects of valve structure and function and their possible clinical relevance were discussed. We now review the clinical evolution and application for various forms of valve repair and outline some of the factors relating to the timing and choice of particular types of repair or replacement and, whenever appropriate, repair versus replacement. In addition, future prospects of valve repair based on understanding of the sophisticated function and structure of valves and the possible future contribution of tissue engineering are discussed.

The very first attempts at surgical treatment of heart valve disease were directed toward repair of mitral stenosis in the early 1920s by Elliot Carr Cutler1 in Boston and Sir Henry Souttar2 in London. Although some of these operations were successful, it was approximately 30 years before mitral valvotomy was established by Bailey in the United States and Lord Brock and O.S. Tubbs in the United Kingdom. The next heart valve operation to be attempted was repair of mitral regurgitation by Lillehei et al,3 who in 1957 reported “surgical correction of pure mitral regurgitation by annuloplasty under direct vision.” Shortly after that, Dwight McGoon,4 at the Mayo Clinic, introduced “repair of mitral regurgitation for ruptured chordae tendineae by triangular resection of the prolapsing segment,” a major contribution. With the introduction of mechanical valve replacement by Harken, Starr, and others and biological valves (homografts) by Donald Ross and Brian Barratt-Boyes in the early 1960s, there was a swing toward valve replacement. More recently, however, there has been a gradual realization that the ideal operation may be a restorative (repair) operation attempting to reproduce some of the sophisticated functions of a normal valve. This was accompanied by refining and evolving new techniques for repair of different valves by Carpentier5 and …

Novel Approaches to Cardiac Valve Repair From Structure to Function: Part II

Effect of Recurrent Mitral Regurgitation Following Degenerative Mitral Valve Repair: Long-Term Analysis of Competing Outcomes.

Mitral valve reconstruction for mitral insufficiency

Mitral valve annuloplasty is a common surgical technique used in the repair of a leaking valve by implanting an annuloplasty device. To enhance repair durability, these devices are designed to increase leaflet coaptation, while preserving the native annular shape and motion; however, the precise impact of device implantation on annular deformation, strain, and curvature is unknown. In this article, we quantify how three frequently used devices significantly impair native annular dynamics. In controlled in vivo experiments, we surgically implanted 11 flexible-incomplete, 11 semi-rigid-complete, and 12 rigid-complete devices around the mitral annuli of 34 sheep, each tagged with 16 equally spaced tantalum markers. We recorded four-dimensional marker coordinates using biplane videofluoroscopy, first with device and then without, which were used to create mathematical models using piecewise cubic splines. Clinical metrics (characteristic anatomical distances) revealed significant global reduction in annular dynamics upon device implantation. Mechanical metrics (strain and curvature fields) explained this reduction via a local loss of anterior dilation and posterior contraction. Overall, all three devices unfavorably caused reduction in annular dynamics. The flexible-incomplete device, however, preserved native annular dynamics to a larger extent than the complete devices. Heterogeneous strain and curvature profiles suggest the need for heterogeneous support, which may spawn more rational design of annuloplasty devices using design concepts of functionally graded materials.

/pdf/mitral-valve-annuloplasty-a-quantitative-clinical-and-8shx53n2zl.pdf

Mitral valve annuloplasty: a quantitative clinical and mechanical comparison of different annuloplasty devices.

Intermediate-term results of a nonresectional dynamic repair technique in 662 patients with mitral valve prolapse and mitral regurgitation

https://www.annalsthoracicsurgery.org/article/S0003-4975(99)00850-4/pdf

Partial tricuspid valve transfer for repair of mitral insufficiency due to ruptured chordae tendineae

Seis pacientes foram submetidos ao tratamento cirurgico da fibrilacao atrial (FA) pela tecnica do labirinto (Cox), sem a uitilizacao da crioblacao. Quatro pacientes apresentavam estenose mitral (EM) associada, 1 insuficiencia mitral e 1 dupla lesao mitral. Um dos pacientes apresentava estenose tricuspide e 2 insuficienciatricuspide associadas. O diâmetro medio do atrio esquerdo, medido pelo ecocardiograma era de 6,0 cm (5-7,3). A etiologia era reumatica em 5 pacientes e degenerativa em 1. Plastia valvar mitral foi realizada em 3 pacientes, comissurotomia mitral em 2 e troca valvar mitral em 1. Em 4 pacientes havia trombos no atrio esquerdo, um deles tambem no atrio direito. O tempo medio de circulacao extracorporea foi de 123 minutos (110-142) e de anoxia do miocardio de 91 minutos (80-108). Na sala de operacoes o ritmo inicial era juncional em 4 e sinusal em 2. No pos-operatorio imediato, todos apresentavam ritmo juncional, passando para ritmo sinusal em todos, exceto em 1. Os pacientes receberam alta hospitalar (8-27 dias) em boas condicoes, sem utilizacao de drogas antiarritmicas e o Holter de 24 horas mostrava ritmo sinusal em 5 pacientes e ritmo atrial ectopico em 1 paciente. O estudo hemodinâmico e o ecodoppler revelaram contracao atrial sincronica em todos os casos, exceto em 1. O diâmetro atrial esquerdo medio era de 4,8 cm (3,7 - 5,2).

http://www.scielo.br/pdf/rbccv/v8n3/v8n3a06.pdf

Técnica de Cox sem crioablação para tratamento cirúrgico da fibrilação atrial

Grafting of chordae tendineae: A new technique for the repair of mitral insufficiency caused by ruptured chordae of the anterior leaflet

A combined mitral reconstructive surgery and Cox-maze operation without cryoablagao was performed in a 12-year-old female patient for the correction of a rheumatic mitral insufficiency and chronic atrial fibrillation. One year postoperative the patient was assymptomatic, in sinusal rhythm and no murmurs were observed. The Doppler echocardiogram showed an important reduction of the left atrial diameter and the cardiac catheterism confirmed an effective atrial systole.

/pdf/correcao-cirurgica-simultanea-da-fibrilacao-atrial-e-da-2gge64logb.pdf

Sergio S. Hayashi

Papers

Partial tricuspid valve transfer for repair of mitral insufficiency due to ruptured chordae tendineae

Técnica de Cox sem crioablação para tratamento cirúrgico da fibrilação atrial

Grafting of chordae tendineae: A new technique for the repair of mitral insufficiency caused by ruptured chordae of the anterior leaflet

Correção cirúrgica simultânea da fibrilação atrial e da insuficiência mitral em criança

Leitura de planilhas de xadrez manuscritas usando redes neurais com mecanismos de atenção