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historical note:

In 1913, Doyen unsuccessfully attempted to relieve pulmonary stenosis with tenotome. 1914, Tuffier successfully relieved 1 case of aortic stenosis with finger dilatation. From 1923 to 1928 Cutler and Souttar reported 10 cases of mitral stenosis surgery - only 2 patients survived these attacts. In 1948, Harken and Bailey, from Boston and Philadelphia, performed their 1st transatrial commissurotomies to treat mitral valve stenosis. John Gibbon performed the 1st successful open-heart operation on a human patient using a heart-lung machine on May 6, 1953, starting the age of open heart surgery. Lillehei is credited with successfully completing the 1st surgical correction of mitral valve insufficiency in 1956. The 1st reported mitral valve replacement took place on July 22, 1955 in England, with Judson Cheesterman performing the surgery.
Within the last decade, mitral valve repair for stenosis and regurgitation has increased dramatically, for 2 reasons: First, mitral valve replacement is associated with long-term complications, also due to anticoagulation. Second, surgeons, since the 1960s, with A. Carpentier, Paris, beeing one of the pioneers in this field, have gradually improved techniques for valve repair and have increased their understanding of functional defects of the mitral valve and associated components.

artificial valves:

 

Biological valves: The most frequent cause of bioprosthetic valve failure is primary tissue degeneration. Toxic preservation and the lack of viable autologous endothelial cells on the leaflet surfaces may be responsible for degeneration and calcification. In the past few years research interest was focused on new techniques to improve conventional bioprostheses by studying possible alternative methods of preservation and in vitro endothelialization, elimination of toxic agents and antimineralization.
degeneration of biological valves: left slide: leaflet rupture right slide: tissue overgrowth & calcification.
 
Mechanical valves: The most frequent limitations of mechanical valves are primarily related to thromboembolism and anticoagulant-related hemorrhage. Mechanical valves will not undergo degeneration, like biological valves. Nevertheless, complications related to thromboembolism and anticoagulant therapy are to be considered if deciding which valve to implant.

complications of mechanical valves: left slide: thrombotic occlusion of a mechanical disc valve right slide: thrombosis of a cached ball mechanical valve (<-)

 
 
 

mitral valve replacement vrs. valve repair:

Although mitral valve reconstruction techniques (to repair and save the valve instead of replacing the valve with an artificial prosthesis) were used successfully in selected patients as early as 1956, mitral valve replacement surgery became a much more widely used procedure in many hospitals. In our hospital over 70% of all mitral valve operations result in a repair and not in a replacement.
 

slide left: "Actual freedom from structural deterioration" Clinical data of the durability of the biological Carpentier Pericardial Valve. The 10 year actuarial freedom from structural deterioration was 91%. Sem Thorac Cardiovasc Surg 1966;8:269-275
slide right:"Freedom from all valve related complications" Freedom from all valve-related complications, according to valve position after mechanical heart valve replacement. (red: mitral valve; green: aortic valve; blue: doubble valve) J Thorac Cardiovasc Surg 1990;100:44-55

slide left: "Mitral valve repair vrs. replacement" Actuarial survival from all cardiac-related death after mitral valve repair vrs. mechanical heart valve replacement. (green: mitral reconstruction; red: mitral replacement) Ann Thorac Surg 1989;47:655-662
slide right:"Mitral valve repair vrs. replacement" Five year actuarial survival after mitral valve repair (green) (annuloplasty), valve replacement with a mechanical valve (red), and with a bioprosthesis (blue). Europ J Cardio-thorac Surg 1990;4:257-264

 

mitral valve repair techniques:
 

slide left: Transplantation of chordae: The cause of mitral valve incompetence in this illustration is a prolaps of the anterior mitral valve leaflet due to ruptured chordae (1). The reconstruction is performed by cutting and resecting a group of chordae from the posterior leaflet (1). This group of chordae is transplanted to the anterior leaflet (2). The reconstruction is finished after a ring implantation (3).
 

slide right: Quadrangular resection of the posterior leaflet: The cause of mitral valve incompetence in this illustrated case is a prolaps of the middle part of the posterior leaflet due to ruptured chordae (1). A quadrangular resection (2) is performed (cutting away the prolapsed excess valve tissue). The annulus is shortened (2) and the leaflets sutured. A mitral valve annuloplasty ring is implanted (3).
 
 

mitral valve repair technique: leaflet plastic / annulus repair / ring implantation
 

Step 1: Assessment of the mitral valve. A prolaps of the posterior leaflet is found (too much tissue) as well as ruptured chordae, causing the incompetence of the valve. Step 2: A quadrangular resection is performed (cutting away the excess valve tissue). The posterior leaflet is cut from the valve annulus. The annulus is shortened. Step 3: A 'sliding leaflet' plastic is performed - by re-adapting the posterior leaflet into the shortened valve annulus. The posterior mitral valve leaflet is reconstructed. Step 4: Reconstruction of the mitral valve annulus. This slide shows the exact measurement of the size of the mitral valve ring to be implanted, using a special 'sizer'.

Step 5: Sutures are put into the mitral valve annulus and the mitral valve ring. Step 6: The reconstructed valve is tested by flushing water into the heart. Step 7: The testing of the valve shows a good result with no residual incompetence. Step 8: Final view of the now reconstructed mitral valve, showing a good result.
 
mitral valve repair technique: annulus repair / ring implantation
 

Step 1: Assessment of the mitral valve. A annular dilatation (the natural mitral valve ring is enlarged) is causing the incompetence of the valve. Step 2: After sizing the size of the mitral valve ring (to reduce the size of the mitral valve annulus) sutures are put into the valve annulus and the ring Step 3: To reconstruct the mitral valve (by reducing the enlarged valve annulus) a mitral valve ring is implanted into the valve annulus. Step 4: Result: The valve is repaired by implantation of a ring, reducing the enlarged annulus and resulting in a competend closure of the valve leaflets.
see mitral valve repair surgical slides ! (click here)
(this site is new !)
 

results:
 

About 400 mitral valve operations are currently performed in our Clinic annually. In our department about 40% of all operations are combined procedures (+ coronary bypass, other valves etc).
About 70% of all mitral valve operations resulted in a successful reconstruction of the mitral valve.
(our results: perioperative mortality for isolated mitral valve reconstruction operations: 0.7%)
 
Intraoperative slide: demonstrating the result of a mitral valve repair operation. The leaflets are repaired, the annuloplasty ring is in place and the valve is shown to be nicely competent.