Clinical effect of loop-in-loop technique and annuloplasty ring for the treatment of mitral valve prolapse under total thoracoscopy_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

WANG Shixiong ¹ , GAO Binren ¹ , LI Ningyin ² , WANG Wei ¹ , WANG Weifan ¹ , MA Qi ¹ , HE Fengxiao ¹ , XUE Yu ¹ ,  LIU Debin ¹

1. Department of Cardiavascular Surgery, The Second Hospital, Lanzhou University, Lanzhou, 730030, P.R.China;
2. Department of Cardiology, The Second Hospital, Lanzhou University, Lanzhou, 730030, P.R.China;

Corresponding?author：

LIU Debin, Email: liudebin01@sina.com

Keywords：

Total thoracoscopy; mitral valve prolapse; artificial chordae; mitral valve repair; minimally invasive surgery

DOI：

10.7507/1007-4848.201810061

Video：

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Objective To analyze the effect of loop-in-loop technique and annuloplasty ring for the treatment of mitral valve prolapse (MVP) under total thoracoscopy.Methods Between May 2012 and May 2017, 21 patients with MVP underwent mitral valve repair in our hospital. There were 12 males and 9 females with a mean age of 50.90±9.66 years and the mean weight of 64.81±11.56 kg. Loop-in-loop artificial chordae tendonae reconstruction and mitral annuloplasty were performed through the right atrial-atrial septal incision under total thoracoscopy. The water test and transesophageal echocardiography were performed during the operation to evaluate the effect of mitral annuloplasty. Data of echocardiography and chest radiography were collected postoperatively one week, before discharge and after discharge.Results All the operations were successful without re-valvupoplasty or valve replacement, conversion to median thoracotomy, malignant arrhythmia, perioperative death or wound infection. Among them, 10 patients underwent tricuspid valvuloplasty, 1 patient underwent tricuspid valvuloplasty plus radiofrequency ablation simultaneously. The mean cardiopulmonary bypass time was 255.57±37.24 minutes, aortic occlusion time was 162.24±19.61 minutes, the number of loop was 2–5 (3.29±0.78), the size of ring was 28–34 (31.11±1.88) mm, ventilator assistance time was 19.43±14.68 hours, ICU time was 58.45±24.60 hours and postoperative hospital stay was 12.28±3.61 days. Transthoracic echocardiography was re-examined postoperatively. Mild-mitral regurgitation was found in 3 patients. Warfarin anticoagulant therapy was given orally for 6 months postoperatively. The patients were followed up regularly for 2–51 months at 1, 3, 6 and 12 months postoperatively. Left ventricular end-diastolic diameter (LVEDD) was 45.06±2.96 mm, left ventricular end-diastolic volume 108.11±17.09 mL, left atrial diameter (LAD) 35.56±6.93 mm and cardiothoracic ratio 0.53±0.13 at discharge which were significantly smaller than those at admission (P<0.05). Pulmonary artery pressure was 19.22±6.38 mm Hg which was significantly lower than that at admission (P<0.05), but left ventricular ejection fraction (62.33%±4.00%) had no significant change (P>0.05). The LAD and LVEDD were significantly smaller than those before operation, and the cardiac function improved to some extent during the follow-up. No new mitral valve prolapse, increased regurgitation, infective endocarditis, thromboembolism or anticoagulation-related complications were found during the follow-up.Conclusion Loop-in-loop artificial chordae tendon implantation combined with mitral annuloplasty is a safe and effective method for MVP under total thoracoscopy with minimal trauma, satisfactory cosmetic effect, and good early- and medium-term results. It is worth of popularizing. However, the operation time needs to be further shortened, and its long-term clinical effect needs further follow-up and other researches to confirm.

Citation： WANG Shixiong, GAO Binren, LI Ningyin, WANG Wei, WANG Weifan, MA Qi, HE Fengxiao, XUE Yu, LIU Debin. Clinical effect of loop-in-loop technique and annuloplasty ring for the treatment of mitral valve prolapse under total thoracoscopy. Chinese Journal of Clinical Thoracic and Cardiovascular Surgery, 2019, 26(8): 759-765. doi: 10.7507/1007-4848.201810061 Copy

1.	Maisano F, Redaelli A, Pennati G, et al. The hemodynamic effects of double-orifice valve repair for mitral regurgitation: a 3D computational model. Eur J Cardiothorac Surg, 1999, 15(4): 419-425.
2.	Nishimura RA, Otto CM, Bonow RO, et al. 2017 AHA/ACC focused update of the 2014 AHA/ACC guideline for the management of patients with valvular heart disease: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol, 2017, 70(2): 252-289.
3.	Bortolotti U, Milano AD, Frater RW. Mitral valve repair with artificial chordae: a review of its history, technical details, long-term results, and pathology. Ann Thorac Surg, 2012, 93(2): 684-691.
4.	Ibrahim M, Rao C, Savvopoulou M, et al. Outcomes of mitral valve repair using artificial chordae. Eur J Cardiothorac Surg, 2014, 45(4): 593-601.
5.	易定華, 俞世強, 徐學增, 等. 我國胸腔鏡微創心臟手術技術操作規范專家共識(征求意見稿第二版). 中國胸心血管外科臨床雜志, 2016, 23(4): 315-318.
6.	Tokunaga S, Yasuda S, Masuda M. Devised loop-in-loop technique in mitral valve repair. Asian Cardiovasc Thorac Ann, 2014, 22(9): 1132-1134.
7.	Coutinho GF, Antunes MJ. Mitral valve repair for degenerative mitral valve disease: surgical approach, patient selection and long-term outcomes. Heart, 2017, 103(21): 1663-1669.
8.	孔燁. 二尖瓣成形技術研究進展. 臨床外科雜志, 2015, 23(9): 655-658.
9.	Morimoto H, Tsuchiya K, Nakajima M, et al. Mitral valve repair for anterior leaflet prolapse: surgical techniques review and 16-year follow-up results. J Card Surg, 2008, 23(5): 426-430.
10.	中華醫學會胸心血管外科分會胸心血管分會心臟瓣膜專業. 中國心臟二尖瓣膜疾病(成人)外科修復技術臨床應用理念. 中華胸心血管外科雜志, 2015, 31(12): 705-714.
11.	Hysi I, Rebet O, Gautier L, et al. A standardized loop technique for mitral valve repair. Ann Thorac Surg, 2017, 103(1): e105-e106.
12.	Okamoto K, Yozu R, Kudo M. Loop-in-loop technique in mitral valve repair via minithoracotomy. Ann Thorac Surg, 2012, 93(4): 1329-1330.
13.	常青, 王吉顯, 吳玉輝, 等. loop或loop in loop技術腱索重建加二尖瓣成形環置入術治療二尖瓣關閉不全. 臨床軍醫雜志, 2016, 44(2): 111-114.
14.	Perier P, Hohenberger W, Lakew F, et al. Toward a new paradigm for the reconstruction of posterior leaflet prolapse: midterm results of the "respect rather than resect" approach. Ann Thorac Surg, 2008, 86(3): 718-725.
15.	David TE, Omran A, Armstrong S, et al. Long-term results of mitral valve repair for myxomatous disease with and without chordal replacement with expanded polytetrafluoroethylene sutures. J Thorac Cardiovasc Surg, 1998, 115(6): 1279-1285.
16.	von Oppell UO, Mohr FW. Chordal replacement for both minimally invasive and conventional mitral valve surgery using premeasured Gore-Tex loops. Ann Thorac Surg, 2000, 70(6): 2166-2168.
17.	Kudo M, Yozu R, Kokaji K, et al. Feasibility of mitral valve repair using the loop technique. Ann Thorac Cardiovasc Surg, 2007, 13(1): 21-26.
18.	姜兆磊, 梅舉, 丁芳寶, 等. 改良人工腱索聯合瓣環成形術在二尖瓣脫垂修復中的應用及遠期隨訪結果. 中國胸心血管外科臨床雜志, 2016, 23(5): 430-433.
19.	Yano M, Sakaguchi S, Furukawa K, et al. A new method for the adjustment of neochordal length: the adjustable slip knot technique. Interact Cardiovasc Thorac Surg, 2015, 21(2): 240-242.
20.	Pomerantzeff PM, Brand?o CM, Leite Filho OA, et al. Mitral valve repair in rheumatic patients with mitral insuficiency: twenty years of techniques and results. Rev Bras Cir Cardiovasc, 2009, 24(4): 485-489.
21.	Zhou YX, Leobon B, Berthoumieu P, et al. Long-term outcomes following repair or replacement in degenerative mitral valve disease. Thorac Cardiovasc Surg, 2010, 58(7): 415-421.

1. Maisano F, Redaelli A, Pennati G, et al. The hemodynamic effects of double-orifice valve repair for mitral regurgitation: a 3D computational model. Eur J Cardiothorac Surg, 1999, 15(4): 419-425.
2. Nishimura RA, Otto CM, Bonow RO, et al. 2017 AHA/ACC focused update of the 2014 AHA/ACC guideline for the management of patients with valvular heart disease: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol, 2017, 70(2): 252-289.
3. Bortolotti U, Milano AD, Frater RW. Mitral valve repair with artificial chordae: a review of its history, technical details, long-term results, and pathology. Ann Thorac Surg, 2012, 93(2): 684-691.
4. Ibrahim M, Rao C, Savvopoulou M, et al. Outcomes of mitral valve repair using artificial chordae. Eur J Cardiothorac Surg, 2014, 45(4): 593-601.
5. 易定華, 俞世強, 徐學增, 等. 我國胸腔鏡微創心臟手術技術操作規范專家共識(征求意見稿第二版). 中國胸心血管外科臨床雜志, 2016, 23(4): 315-318.
6. Tokunaga S, Yasuda S, Masuda M. Devised loop-in-loop technique in mitral valve repair. Asian Cardiovasc Thorac Ann, 2014, 22(9): 1132-1134.
7. Coutinho GF, Antunes MJ. Mitral valve repair for degenerative mitral valve disease: surgical approach, patient selection and long-term outcomes. Heart, 2017, 103(21): 1663-1669.
8. 孔燁. 二尖瓣成形技術研究進展. 臨床外科雜志, 2015, 23(9): 655-658.
9. Morimoto H, Tsuchiya K, Nakajima M, et al. Mitral valve repair for anterior leaflet prolapse: surgical techniques review and 16-year follow-up results. J Card Surg, 2008, 23(5): 426-430.
10. 中華醫學會胸心血管外科分會胸心血管分會心臟瓣膜專業. 中國心臟二尖瓣膜疾病(成人)外科修復技術臨床應用理念. 中華胸心血管外科雜志, 2015, 31(12): 705-714.
11. Hysi I, Rebet O, Gautier L, et al. A standardized loop technique for mitral valve repair. Ann Thorac Surg, 2017, 103(1): e105-e106.
12. Okamoto K, Yozu R, Kudo M. Loop-in-loop technique in mitral valve repair via minithoracotomy. Ann Thorac Surg, 2012, 93(4): 1329-1330.
13. 常青, 王吉顯, 吳玉輝, 等. loop或loop in loop技術腱索重建加二尖瓣成形環置入術治療二尖瓣關閉不全. 臨床軍醫雜志, 2016, 44(2): 111-114.
14. Perier P, Hohenberger W, Lakew F, et al. Toward a new paradigm for the reconstruction of posterior leaflet prolapse: midterm results of the "respect rather than resect" approach. Ann Thorac Surg, 2008, 86(3): 718-725.
15. David TE, Omran A, Armstrong S, et al. Long-term results of mitral valve repair for myxomatous disease with and without chordal replacement with expanded polytetrafluoroethylene sutures. J Thorac Cardiovasc Surg, 1998, 115(6): 1279-1285.
16. von Oppell UO, Mohr FW. Chordal replacement for both minimally invasive and conventional mitral valve surgery using premeasured Gore-Tex loops. Ann Thorac Surg, 2000, 70(6): 2166-2168.
17. Kudo M, Yozu R, Kokaji K, et al. Feasibility of mitral valve repair using the loop technique. Ann Thorac Cardiovasc Surg, 2007, 13(1): 21-26.
18. 姜兆磊, 梅舉, 丁芳寶, 等. 改良人工腱索聯合瓣環成形術在二尖瓣脫垂修復中的應用及遠期隨訪結果. 中國胸心血管外科臨床雜志, 2016, 23(5): 430-433.
19. Yano M, Sakaguchi S, Furukawa K, et al. A new method for the adjustment of neochordal length: the adjustable slip knot technique. Interact Cardiovasc Thorac Surg, 2015, 21(2): 240-242.
20. Pomerantzeff PM, Brand?o CM, Leite Filho OA, et al. Mitral valve repair in rheumatic patients with mitral insuficiency: twenty years of techniques and results. Rev Bras Cir Cardiovasc, 2009, 24(4): 485-489.
21. Zhou YX, Leobon B, Berthoumieu P, et al. Long-term outcomes following repair or replacement in degenerative mitral valve disease. Thorac Cardiovasc Surg, 2010, 58(7): 415-421.

Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Clinical effect of loop-in-loop technique and annuloplasty ring for the treatment of mitral valve prolapse under total thoracoscopy

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