Mitral valve replacement with complete mitral leaflet retention: operative techniques

This report describes surgical indication and operative technique of complete preservation of the mitral valvular and subvalvular apparatus during mitral valve replacement.

Twenty patients, 12 with rheumatic lesions and eight with congenital lesions, were operated between 1991 and 1996. The left atrium was opened using a trans-septal approach through the right atrium in 17 patients, and at the intra-atrial groove in three. The valve was sized without excising any mitral valvular or subvalvular tissue. Teflon pledget-reinforced horizontal mattress valve sutures were passed from the left atrium, through the mitral annulus, around the free edge of mitral leaflet, and up through the prosthetic sewing ring. The prosthetic valve was seated and the sutures tied, reefing the native leaflets and compressing them between the sewing ring and native annulus. Thus, chordal tension on the ventricle was evenly maintained.

There was no operative or late death. Postoperative results were excellent. Echocardiography showed that none of the patients had any observable anterior leaflet and redundant subvalvular tissue in the left ventricular outflow tract (LVOT); thus, neither LVOT obstruction nor interference with prosthetic valve function occurred.

Based on these findings, it is suggested that when mitral valve replacement is required in patients with mitral insufficiency (MI) or MI with mild stenosis, the mitral valvular and subvalvular tissue should be completely preserved.