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Isolated mitral valve replacement and ventricular rupture: presentation of 6 patients
Insights
Ventricular wall rupture after mitral valve replacement is a serious complication. A revised surgical technique, avoiding sutures in heart muscle, significantly reduced rupture incidence.
Area of Science:
- Cardiovascular Surgery
- Cardiac Surgery
- Surgical Complications
Background:
- Ventricular wall rupture is a rare but devastating complication following mitral valve replacement (MVR).
- Understanding the specific causes and risk factors is crucial for improving patient outcomes.
Observation:
- This review examines 6 cases of ventricular wall rupture post-isolated MVR.
- Rupture was associated with severe mitral stenosis and calcification in 2 patients, likely due to myocardial injury during valve removal.
- In 4 patients with mitral insufficiency, rupture occurred without significant calcification, with perforations noted beneath the annulus.
Findings:
- During a period when cardioplegic solutions were newly introduced, MVR had a 7.3% rupture incidence (55 patients), becoming a leading cause of mortality.
- A modified surgical technique, involving preservation of the posterior leaflet and chords, and suturing only in fibrous tissue, was implemented.
- Following this technique modification, no further ruptures occurred in 23 subsequent MVR procedures.
Implications:
- The findings highlight the critical importance of surgical technique in preventing ventricular wall rupture during MVR.
- Modifying suture placement to avoid myocardial tissue is a key strategy for reducing this severe complication.
- This revised approach offers a promising method to enhance safety and reduce mortality in mitral valve surgery.
Abstract:
The cases of 6 patients who had ventricular wall rupture after isolated mitral valve replacement and were seen in our service are reviewed. In the first 2, the main lesion was mitral stenosis and calcification was severe. Injury to the ventricular myocardium during removal of the valve was the causative factor in 1 and the most likely explanation in the other. In the other 4 patients, the dominant lesion was insufficiency. Calcium was absent, and fibrosis of the valves was minimal. Defects of technique were not obvious. All perforations were beneath the annulus. The first of these 4 latter patients underwent operation just after cardioplegic solutions were introduced for myocardial protection in our service. During that period, the incidence of ventricular wall rupture was 7.3% for mitral valve replacement (55 patients). Causing 3 deaths, it became the most important mortality factor. After reviewing the problem, we decided to change our technique by leaving practically all the posterior leaflet and most of the chords intact and placing sutures through fibrous tissue only, never into muscle, as had already been suggested. Since then, we have not seen another rupture in 23 valve replacements.