MITRAL VALVE REPLACEMENT
TECHNIQUE
STEPS
- Optimally started by a short incision at the base of the AML at the 12 o'clock position
- A pledgeted mattress stitch is placed into the mitral annulus at the point of incision then using it to pull the annulus into the operative field.
- AML is then circumferentially incised as far as the commissures
- Chordae are divided at the tip of the papillary muscles.
- PML is left intact preserving the ventriculo-annular continuity.
- In MS with suitable morphology.
- In MR unsuitable for repair with a dilated severely impaired LV.
Beginning of AML Excision
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Excision of the AML
Chordae to the PML are preserved |
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Advantages of PML Preservation:
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Partial preservation of the AML and commissural fixation with preservation of PML
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Mattress sutures placement into the mitral annulus with pledgets on supraannular side
[Everting stitch]
[Everting stitch]
- Interrupted pledgeted mattress stitches are commonly used.
- In a well-accessible firm annular tissue, a continuous stitch may be used.
- Bileaflet prosthesis are positioned anti-anatomically (slit between the two leaflets is orientated perpendicular to the coaptation zone of of AML and PML) for optimal haemodynamics.
St. Jude Medical valve seated in the mitral annulus in anti-anatomical orientation
before tying of the sutures |
Bioprosthesis St. Jude Medical Epic implanted into the mitral position
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Excessive Annular Calcifications:
Excessive annular calcifications in PML area
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MVR with preservation of annular calcications
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Atrioventricular Groove Disruption:
Myocardial injury caused by scissors tips can cause LV rupture
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Sharp cardiotomy sucker may injure the myocardium and cause LV rupture
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Myocardial tear caused by bioprosthesis strut during suture tying
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Incorrect placement of a suture too deep in myocardium may cause LV rupture
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