Mitral valve replacement with total preservation of native valve and subvalvular apparatus

Preservation of the mitral valve and subvalvular apparatus was introduced clinically in the early 1960s, but for two decades the technique for mitral valve replacement included excision of both leaflets and their attached chordae tendineae. Lately, emphasis has been replaced on retaining the mitral subvalvular apparatus during valve replacement because of its role in left ventricular function. Hence, during the past six years, when performing mitral valve replacement we have, when possible, preserved the valvular and sub-valvular mitral apparatus.

Between January 1990 and November 1996, complete retention of all mitral tissue in connection with mitral valve replacement was performed in 58 patients (23 women and 35 men). Mean age was 63 years (range: 23 years to 77 years). Coronary bypass was a concomitant procedure in 19 patients; both the mitral and aortic valve was replaced in four cases. Calcified and/or stenotic valves were not a contraindication for the procedure; calcified plaques were removed. Adhesion between anterior and posterior leaflets was treated with sharp dissection. Valve and subvalvular tissue were preserved. The leaflets were reefed within the valve-sutures and compressed between the sewing ring and the native annulus when implanting the valve prosthesis. Chordal tension on the ventricle is thus maintained and the chordae pulled away from the valve effluent.

Six patients died in the postoperative period and three had transient neurological symptoms. In no patient was death or transient neurological symptoms a consequence of the retention of mitral leaflets with subvalvular apparatus.

We find the described technique to be useful not only in valve insufficiency but also in valve stenosis when preserving the mitral leaflets with sub-valvular apparatus during valve replacement. The technique is without procedure-related complications and prevents obstruction of left ventricular outflow tract.