Expanding the use of total mitral valve preservation in combination with implantation of the CarboMedics heart valve prosthesis

Background, Preservation of the mitral valve and subvalvular apparatus was introduced into the clinic in the early sixties, but for two decades the st andard technique for mitral valve replacement included excision of both lea flets and their attached chordae tendineae. Lately, increased emphasis has again been placed on retention of the mitral subvalvular apparatus during v alve replacement because of its role on left ventricular function. Methods. We have preserved the valvular and subvalvular mitral apparatus, w hen possible, in connection with mitral valve replacement during the last s even years and the present investigation (partly prospective and partly ret rospective) was done with the aim of making up the results of our mitral pr eservation technique. In the period between January 1990 and December 1995, 30% of the patients who underwent mitral valve replacement had complete re tention of all mitral tissue. In 1996, the percentage had increased to 50, and during the first seven months of 1997, 70% of the patients had complete retention of all mitral tissue. Since January 1997, we have exclusively us ed the CarboMedics mitral heart valve prosthesis. A total of 56 patients we re identified to have had a CarboMedics heart valve prosthesis implanted. T here were 33 men and 23 women with a mean age of 63 years, range 23-77 year s. Coronary bypass was a concomitant procedure in 22 patients. In seven pat ients, both the mitral and aortic valves were replaced. A severely altered valve with thickened and or calcified leaflets, stenotic leaflets, or short ened, retracted and thickened chordae tendineae were not a contraindication for the procedure. Calcified plaques were removed. Adhesion between anteri or and posterior leaflets was treated with sharp dissection. Valve and subv alvular tissue were preserved. The leaflets were reefed within the valve-su tures and compressed between the sewing ring acid the native annulus when i mplanting the valve prosthesis. Chordal tension on the ventricle was thereb y maintained and the chordae pulled away from the valve effluent. Echocardi ography with measurement of ejection-fraction was performed preoperatively during the postoperative course in case of cardiac problems and on a routin e basis 1 month after surgery and at various intervals when the patient was seen in the outpatient clinic. Left ventricular outflow tract gradients we re measured during the postoperative course in case of cardiac problems and routinely 1 month postsurgically. Results. Five patients died in the postoperative period and one patient had transient neurological symptoms. In none of the patients was death or tran sient neurological symptoms a consequence of the retention of mitral leafle ts with subvalvular apparatus. The remaining 51 patients were all alive at follow-up. Postoperative echocardiography demonstrated a preserved;left ven tricular function and a left ventricular outflow tract without obstruction. Conclusions. We find that the described technique in combination with impla ntation of a CarboMedics heart valve prosthesis is very useful even in pati ents with a severely altered valve, when preserving the mitral leaflets wit h subvalvular apparatus during valve replacement. The technique is without procedure related complications and preserves left ventricular function wit hout obstructing the left ventricular outflow tract.