Mitral Valve Replacement After Late Failure of Mitral
Valve Repair
A. Marc Gillinov, MD
itral valve repair is the preferred surgical treat-
M ment for mitral valve dysfunction. Although the
feasibility of mitral valve repair extends to 95% of
patients with degenerative valvular disease and up to
75% of patients with rheumatic or ischemic valvular
disease, nearly all reports describe patients who have
required reoperation for recurrent mitral valve dys-
function.1-5 Late reoperation after mitral valve repair is
required in 5% to 10% of patients with degenerative
disease and 25% to 50% of patients with rheumatic
disease.1-5
Reoperation after mitral valve repair poses specific
challenges related to choice of procedure and surgical
42 Operative Techniques in Thoracic and Cardiovascular Surgery, Vol 8, No 1 (February), 2003: pp 42-50
technique. Should the dysfunctional valve, which has
been repaired once, be re-repaired or replaced? Except
for instances of recurrent, localized degenerative dis-
ease and early technical failure (eg, suture or ring
dehiscence), we favor valve replacement. How should
the valve be approached? Median sternotomy with left
atriotomy is our preferred approach. However, alter-
native strategies are useful in particular situations.
Right thoracotomy may be used when patent grafts are
in danger at resternotomy, and an extended transseptal
incision on the heart exposes the mitral valve in the
setting of a small left atrium (less than 4 cm in maximal
dimension).
MITRAL VALVE REPLACEMENT AFTER LATE FAILURE OF MITRAL VALVE REPAIR 43

1 Standard left atrial approach to the mitral valve. A median sternotomy has been performed, and the right side of the
heart and aorta dissected. Venous cannulation is achieved via cannulae in the superior and inferior vena cavae. After
commencing cardiopulmonary bypass, the left side of the heart is dissected to improve exposure of the mitral valve;
alternatively, the left pleural space is opened, allowing the heart to fall to the left. The mitral valve is approached via a
standard left atriotomy anterior to the pulmonary veins. Dissection of the interatrial groove further improves exposure,
bringing the surgeon closer to the anterior mitral annulus. The atriotomy is extended beneath the superior and inferior vena
cavae.
44 A. MARC GILLINOV

2 Extended transseptal approach to the mitral valve. The heart is approached via median sternotomy, the right side and
aorta dissected, and standard bicaval venous cannulation performed. The superior vena cava is mobilized widely, and
adhesions between the aorta and dome of the left atrium are cut. It is not necessary to dissect the left side of the heart when
the transseptal approach is employed. (A) After the caval snares are tightened, a right atriotomy is constructed. A retrograde
cardioplegia catheter is placed at this time. (B) The septum is incised, and this incision is carried onto the dome of the left
atrium superiorly. The incision should not come too close to the aorta, as this complicates closure.
MITRAL VALVE REPLACEMENT AFTER LATE FAILURE OF MITRAL VALVE REPAIR 45

2c (C) The septum and dome of the left atrium are retracted with stay sutures and hand-held retractors, exposing the
mitral valve.
46 A. MARC GILLINOV

3A,B Chordal-sparing mitral valve replacement for recurrent degenerative disease. The previous operation included
posterior leaflet quadrangular resection and annuloplasty. (A) Now there is extensive chordal rupture of the anterior leaflet,
and valve replacement is chosen. (B) The annuloplasty band is removed and the previous repair is taken down.
MITRAL VALVE REPLACEMENT AFTER LATE FAILURE OF MITRAL VALVE REPAIR 47

3c, d (C) An ellipse of anterior leaflet tissue is resected, preserving the free edge and its chordae. The remaining
posterior leaflet and its chordae are preserved. Sutures are passed through the annulus and leaflet tissue, with the pledgets
on the atrial side. If the annulus is not pliable, pledgets may be placed on the ventricular aspect. (D) Sutures are passed
through the sewing ring of the prosthesis, and the valve is seated.
48 A. MARC GILLINOV

4 Mitral valve replacement after previous repair for rheumatic disease. (A) After previous repair for rheumatic mitral
regurgitation, the valve has developed typical features of mitral stenosis. Such a valve should be replaced. (B) The
annuloplasty band is removed. Where possible, the subvalvular apparatus is preserved. Often, severe thickening of the
subvalvular apparatus and calcification of the leaflets and annulus make resection necessary. In the pictured case, the free
edge of the anterior leaflet can be preserved along with a portion of the posterior leaflet. Sutures are passed through the
annulus and through remaining leaflet tissue, the pledgets positioned on the atrial side if the annulus is pliable or on the
ventricular aspect if the annulus is very stiff. If the annulus is small, placement of pledgets on the ventricular side facilitates
insertion of a prosthesis of adequate size. (C) The prosthesis is seated.
MITRAL VALVE REPLACEMENT AFTER LATE FAILURE OF MITRAL VALVE REPAIR 49

5 Mitral valve re-repair for recurrent degenerative disease. (A) The previous repair included posterior leaflet resection and
annuloplasty. Now there is localized chordal rupture at the posterior leaflet, a situation favorable for re-repair. (B) The
annuloplasty band is removed and a limited posterior leaflet resection is performed. (C) The annulus is plicated with a
pledgetted suture and the leaflet edges reapproximated with running suture. (D) A new annuloplasty band is inserted.
50
COMMENTS
Among 81 patients having reoperation for failed mitral
alve repair, the most common causes of recurrent mitral
valve dysfunction were procedure- and valve-related.4
Procedure-related failures represented technical errors,
and with increased experience, have become infrequent.
The most common cause of valve-related repair failure
was progression of primary valve disease. This is a
particular issue in patients with rheumatic etiology.
Before surgery, the precise mechanism of repair fail-
ure must be identified by echocardiography. Advanced
age or a history of coronary artery disease mandate
coronary angiography. If endocarditis is the cause of
valve dysfunction, then antibiotics are started. In most
patients, surgery can be performed electively.
Our preferred chest-wall incision is median sternot-
omy. This facilitates standard cannulation for cardio-
pulmonary bypass, excellent myocardial protection,
coronary artery bypass grafting if necessary, and con-
trol of a patent internal thoracic artery graft. A right
thoracotomy is used only in particular instances; these
include a patent bypass graft at particular risk of
injury with repeat sternotomy1 and very early reopera-
tion (⬍6 months),2 at which time adhesions are partic-
ularly challenging. The right thoracotomy approach
may be associated with postoperative low cardiac out-
put syndrome, possibly related to inadequate myocar-
dial protection.6
If the left atrium is large, then the mitral valve is
approached via left atriotomy. If the left atrium is small
A. MARC GILLINOV
or if the surgeon does not wish to dissect the left side of the
heart, then an extended transseptal incision is employed.
In most instances, the valve is replaced. When pos-
sible, the subvalvular apparatus is preserved, although
this may not be possible in patients with severe rheu-
matic disease. Occasionally patients with recurrent,
localized degenerative disease can be treated by re-
repair.
REFERENCES
1. Deloche A, Jebara VA, Relland JYM, et al: Valve repair with Carpen-
tier techniques: the second decade. J Thorac Cardiovasc Surg 99:990-
1002, 1990
2. Braunberger E, Deloche A, Berrebi A, et al: Very long-term results
(more than 20 years) of valve repair with Carpentier’s techniques in
nonrheumatic mitral valve insufficiency. Circulation 104(Suppl I):I8-
I11, 2001
3. Gillinov AM, Cosgrove DM, Blackstone EH, et al: Durability of mitral
valve repair for degenerative disease. J Thorac Cardiovasc Surg 116:
734-743, 1998
4. Gillinov AM, Cosgrove DM, Lytle BW, et al: Reoperation for failure of
mitral valve repair. J Thorac Cardiovasc Surg 113:467-475, 1997
5. David TE, Armstrong S, Sun Z, et al: Late results of mitral valve
repairfor mitral regurgitation of the myxomatous valve. Ann Thorac
Surg 56:7-14, 1993
6. Adams DH, Filsoufi F, Byrne JG, et al: Mitral valve repair in redo
cardiac surgery. J Card Surg 17:40-45, 2002
From the Department of Thoracic and Cardiovascular Surgery, The Cleveland
Clinic Foundation, Cleveland, OH.
Address reprint requests to A. Marc Gillinov, MD, Department of Thoracic and
Cardiovascular Surgery, The Cleveland Clinic Foundation/F25, 9500 Euclid Av-
enue, Cleveland, OH 44195.
Copyright 2003, Elsevier Science (USA). All rights reserved.
1522-2942/03/0801-0000$35.00/0
doi:10.1053/otct.2003.?????