Midterm Results of Mitral Valve Repair With
Homemade Annuloplasty Rings
Wiwat Warinsirikul, MD, Pirapat Mokarapong, MD, Surapot Sangchote, MD,
Sant Chaiyodsilp, MD, and Supreecha Tanamai, MD
Institute of Cardiovascular Diseases, Rajavithi Hospital, Bangkok, Thailand
Background. There are many kinds of prosthetic mitral
annuloplasty rings. We report results of our homemade
annuloplasty rings.
Methods. Between January 1991 and January 1998, 107
patients with mitral insufficiency underwent mitral valve
repair with homemade annuloplasty rings. Mitral insuf-
ficiency was due to rheumatic disease in 71 patients,
degenerative disease in 29, endocarditis in 3, and congen-
ital heart disease in 4 patients. A total of 67 patients were
in New York Heart Association functional class III or IV
preoperatively. Midterm follow-up was available in 106
patients from 1 month to 6.6 years (average, 2.4 years).
M itral valve repair has been used with increasing
frequency for the surgical treatment of patients
with mitral valve disease. Many kinds of annuloplasty
rings and bands are being used [1– 4]. This study de-
scribes our experience of midterm results of mitral valve
repair with homemade polytetrafluoroethylene (PTFE)
annuloplasty rings.
Patients and Methods
Between January 1991 and January 1998, 107 patients with
mitral valve insufficiency underwent repair with mitral
annuloplasty. There were 44 men and 63 women, age
ranged from 3 to 68 years (average, 28 years). Criterion
for mitral valve repair in this study was significant mitral
regurgitation with progressive left ventricular dilatation.
Exclusion criteria were calcified or severe fibrotic valves.
Severe shortening and fusion of chordae and papillary
muscles, prolapse, or destroyed leaflet that required
resection more than one fourth of its length were also
excluded. Informed consent was obtained from all pa-
tients before participation in this study. This study was
approved by the Board of Institute of Cardiovascular
Diseases, Rajavithi Hospital on January 3, 1991.
The cause of mitral regurgitation was rheumatic heart
disease in 71 patients (66.4%), degenerative disease in 29
(27.1%), endocarditis in 3 (2.8%), and congenital heart
disease in 4 patients (3.7%). All patients had significant
mitral regurgitation. The associated lesions and operative
findings are shown in Table 1. Seven patients (6.5%) were
Accepted for publication Jan 16, 1999.
Address reprint requests to Dr Warinsirikul, Institute of Cardiovascular
Diseases, Rajavithi Hospital, 2 Rajavithi Rd, Bangkok 10400, Thailand.
© 1999 by The Society of Thoracic Surgeons
Published by Elsevier Science Inc
Results. Operative mortality was 0.9%. At 5 years,
survival and event-free survival rates were 92% and 80%,
and freedom from thromboembolic complications and
reoperation were 95% and 93%, respectively. Ninety-
three patients (97%) were in New York Heart Association
functional class I, 3 patients (3%) were in class II.
Echocardiography at follow-up showed satisfactory mi-
tral valve function.
Conclusions. Midterm results of homemade annulo-
plasty rings are comparable to commercial ones.
(Ann Thorac Surg 1999;67:63– 6)
© 1999 by The Society of Thoracic Surgeons
in New York Heart Association functional class I, 33
(30.8%) were in class II, 45 (42.1%) were in class III, and 22
(20.6%) were in class IV. Forty-four patients (41.1%) were
in sinus rhythm and 63 patients (58.9%), in atrial
fibrillation.
All patients had echocardiograms before operation;
75% showed severe mitral regurgitation and 25% mod-
erate regurgitation with associated mitral stenosis.
Annuloplasty Rings
Our rings were constructed with 4-mm diameter PTFE
tube and No. 1 stainless-steel wire. A segment of approx-
imately 11-cm long wire was placed inside the lumen of
the 10-cm long PTFE tube. The ring was constructed on a
cylinder of 3 cm in diameter, as shown in Figure 1. Both
ends of the wire were then twisted together making a
circular ring of 10 cm in circumference. In such a way this
would be approximately 3 cm in diameter and 6.0 to 7.0
cm2 in cross-sectional area. Both ends of the PTFE tube
were sewn together with silk. The constructing process
was completed. The ring could be reshaped manually to
different shapes such as circular, ellipsoid, or asymmet-
ric. Because the framework of the ring was not rigid, its
configuration changed during cardiac cycle; therefore,
the ring was flexible. The cost of a ring was $150 US.
We used the same concepts of mitral valve repair
described by Carpentier and associates [1].
Rheumatic patients had more severe fibrotic valves
and required more aggressive mobilization technique.
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64 WARINSIRIKUL ET AL Ann Thorac Surg
HOMEMADE MITRAL ANNULOPLASTY RINGS 1999;68:63– 6

Table 1. Operative Findings and Associated Lesions (n ⫽ 107)

No. of Patients
Variable (%)

Annular dilatation 106 (99.0)

Chordal fusion 53 (49.5)
Prolapse 38 (35.5)
Commissural fusion 30 (28.0)
Chordal elongation 28 (26.2)
Chordal rupture 16 (15.0) Fig 2. The annuloplasty ring after implantation.
Leaflet rupture 2 (1.9)
Tricuspid regurgitation 47 (43.9)
vived the operation from 1 month to 6.6 years, with a total
Aortic regurgitation 29 (27.1)
of 256.1 patient-years. Transthoracic echocardiography
Atrial septal defect 10 (9.3)
was performed at 1 week, 1 year, and 5 years after the
operation in all patients except those who had reopera-
tions for mitral valve replacement. The ␹2 and Student’s
The frequent surgical techniques used for rheumatic
t test were used for statistical analysis of difference
heart disease were chordal and papillary muscle split-
between preoperative and postoperative data character-
ting; for degenerative disease, leaflet resection and
istics. Survival analysis was evaluated by Kaplan-Meier
chordal shortening plasty. Our annuloplasty ring was
method [5].
first shaped into shorter (4-cm) anterior portion and a
longer (6-cm) posterior portion, then implanted on mitral
annulus accordingly with interrupted mattress sutures. Results
The mitral competency was tested after repair by passing
Hospital mortality was 1 patient (0.9%). One patient was
a 12F cannula into the left ventricle through cardioplegic
excluded, he required mitral valve replacement because
hole in the ascending aorta. Water was injected to fill the
of failure of repair caused by restricted valve mobility.
left ventricle to test the competency of the mitral valve
Late deaths occurred in 5 patients. The causes of death
(Fig 2). The shape of the ring was reformed in some ways,
ware cerebral hemorrhage due to warfarin overdose (1
for example, change of the curvature, anterior–posterior
patient), cerebral embolism (1), endocarditis (1), and
distance to achieve the best competency. Associated
unknown (2 patients). Survival at 5 years was 92% (op-
lesions were also repaired.
erative mortality included) (Fig 3). Event-free survival at
All patients received warfarin for 6 weeks postopera-
5 years was 80%, being better for degenerative disease,
tively. Patients with atrial fibrillation received long-term
which was 92% (operative mortality included) (Fig 4).
warfarin. Follow-up is complete in all patients who sur-
There were four thromboembolic events in 4 patients
for an embolic rate of 1.6% per patient-year. All the
events occurred in rheumatic patients who had atrial
fibrillation. Freedom from thromboembolic events at 5
years was 95% (Fig 5). Mitral valve replacement was
necessary in 4 patients, 2 patients (1.9%) required reop-
eration within 1 year. Three patients had rheumatic heart
disease and the other had degenerative disease. The

Fig 1. The construction of the annuloplasty ring. (A) A segment of

approximately 11-cm long wire was placed inside the lumen of the
10-cm long polytetrafluoroethylene tube. The ring was constructed
on a cylinder 3 cm in diameter. Both ends of the wire were then
twisted together. (B) Both ends of the polytetrafluoroethylene tube Fig 3. Survival after annuloplasty in rheumatic and degenerative
were sewn together with silk. (C) The constructing process was disease. (DD ⫽ degenerative disease; N ⫽ number at risk; RHD ⫽
completed. rheumatic heart disease; Total ⫽ all patients.)
Ann Thorac Surg WARINSIRIKUL ET AL 65
1999;68:63– 6 HOMEMADE MITRAL ANNULOPLASTY RINGS

Fig 4. Event-free survival in rheumatic and degenerative disease. Fig 6. Reoperation-free survival in rheumatic and degenerative dis-
(DD ⫽ degenerative disease; N ⫽ number at risk; RHD ⫽ rheu- ease. (DD ⫽ degenerative disease; N ⫽ number at risk; RHD ⫽
matic heart disease; Total ⫽ all patients.) rheumatic heart disease; Total ⫽ all patients.)

causes of reoperation were restrictive valve motion in 3
patients and ruptured chordae in 1 patient. Freedom
from reoperation was 93% at 5 years (Fig 6). The reop-
eration rate was 1.6% per patient-year.
The patients’ functional class was significantly im-
proved after operation. Ninety-three patients (97%) were
in class I and 3 patients (3%) were in class II (p ⬍ 0.01).
Results of echocardiography are shown in Table 2 and
Figure 7. No systolic anterior motion of the mitral valve
was observed.
Comment
The function of the annuloplasty ring is to restore dilated
mitral annulus. In this study we try to evaluate our
homemade PTFE ring. We do not construct the ring
according to the length of anterior part of mitral annulus.
Diameter of the handmade annuloplasty ring is fixed at
30 mm in the present series based on our experience of
mitral valve replacement. The follow-up echocardiogra-
phy could demonstrate that the orifice was quite ade-
quate. One advantage of this ring is that it is reshapable.
Its shape can be adjusted manually to achieve the best
competence during operation. In our experience, adjust-
ment of ellipsoid shape of the ring gave the best compe-
tency. Postoperative echocardiography showed good re-
sults of the repair and mitral annulus was restored to
normal size and shape.
The predictability of the technique is demonstrated by
the low incidence of early reoperation (1.9% at 1 year).
Prosthetic ring dehiscence has not been seen in our
study. Some reports on the use of annuloplasty rings
showed incidences of ring dehiscence from negligible to
2.88% [2, 3, 6, 7].
Patients’ survival in this study was 92% at 5 years,
which was comparable to other series using commer-
cially available rings [1– 4, 6, 7]. The incidence of reop-
eration was 1.6% per patient-year with 93% freedom from
reoperation at 5 years. Most reoperations were per-
formed in the rheumatic patients because the valves were
more fibrotic and the progressive rheumatic process. In
our rheumatic patients, we found that there was an
increasing degree of regurgitation during follow-up. This
study also confirms other reports that the patients with

Table 2. Echocardiographic Dataa

Postop
Preop 1 Week 1 Year 5 Years
Variable (n ⫽ 107) (n ⫽ 106) (n ⫽ 70) (n ⫽ 12)

EDV (mL) 306 ⫾ 153 182 ⫾ 108b 188 ⫾ 107b 182 ⫾ 79b
ESV (mL) 103 ⫾ 63 95 ⫾ 76 74 ⫾ 62b 69 ⫾ 34b
EF (%) 66 ⫾ 11 49 ⫾ 17b 61 ⫾ 11b 62 ⫾ 10
MVA-p (mm2) 364 ⫾ 169 286 ⫾ 100b 284 ⫾ 95b 207 ⫾ 41b
MVA-d (mm2) 241 ⫾ 91 235 ⫾ 68 203 ⫾ 54b 187 ⫾ 52b
MPG (mm Hg) 8.9 ⫾ 5.6 4.5 ⫾ 1.9b 6.1 ⫾ 2.6b 5.1 ⫾ 1.4b
a
Data are means ⫾ standard deviation. b
p ⬍ 0.01 versus preopera-
tive measurement.
EDV ⫽ end-diastolic volume; EF ⫽ ejection fraction; ESV ⫽ end-
systolic volume; MPG ⫽ mean pressure gradient across mitral valve;
Fig 5. Thromboembolism-free survival in rheumatic and degenera-
MVA-d ⫽ mitral valve area (Doppler); MVA-p ⫽ mitral valve area (planim-
tive disease. (DD ⫽ degenerative disease; N ⫽ number at risk; etry); n ⫽ number of patients; Postop ⫽ postoperative measurement;
RHD ⫽ rheumatic heart disease; Total ⫽ all patients.) Preop ⫽ preoperatie measurement.
66 WARINSIRIKUL ET AL
HOMEMADE MITRAL ANNULOPLASTY RINGS
Fig 7. Echocardiography showed marked decrease of mitral regurgi-
tation after repair. *p ⬍ 0.01 versus preoperative measurement. (N
⫽ number of patients; Preop ⫽ before operation; 1 week, 1 year, 5
years ⫽ time after operation.)
degenerative disease have a more favorable outcome [2,
6, 8].
Incidence of thromboembolic complications in this
study was 1.6% per patient-year. Some reports showed
thromboembolic rates of 0.6% to 2.52% per patient-year
[1, 9]. Therefore, thromboembolism may not relate to the
type of rings. Risk factor for thromboembolism is atrial
fibrillation; therefore, the patient who has a risk factor
should receive an anticoagulant.
We believe that our handmade annuloplasty ring is
cheap and gives excellent outcome comparable to the
other commercially available rings. The technique is
reproducible and this ring is an alternative for using
other commercial rings.
In summary, this study shows the good midterm re-
sults of our handmade annuloplasty ring. The main
function of the ring is to restore dilated mitral annulus. It
can be made very easily and it is cheap. Long-term
follow-up is required to confirm the stability of this
report.
Ann Thorac Surg
1999;68:63– 6
Limitation of this study is that we could not demon-
strate the flexibility of our ring due to the lack of
multiplane transesophageal echocardiography in our
institute.
We thank our cardiologists: Drs Wilai Puawilai, Sirichai Tana-
sarnsombat, Saowaluk Prompongsa, Tanarat Choon-ngam,
Donpichit Laorakpongse, Poonchai Jitanantwitaya, Sutham
Sutheerapatranont, Thanarat Layangool, Chaisit Sangtawesin,
and Vachara Jamjureeruk for echocardiography. We thank Dr
Suree Athapaisalsarudee, for the original idea, which led to the
development of the annuloplasty ring, and Dr Pantpis Sakorn-
pant for his tremendous help and in-depth critique of this study.
References
1. Carpentier A, Chauvaud S, Fabiani JN, et al. Reconstructive
surgery of mitral valve incompetence. Ten-year appraisal.
J Thorac Cardiovasc Surg 1980;79:338– 48.
2. Deloche A, Jebara VA, Relland JYM, et al. Valve repair with
Carpentier techniques. J Thorac Cardiovasc Surg 1990;99:990 –
1002.
3. Cosgrove DM, Chavez AM, Lytle BW, et al. Results of mitral
valve reconstruction. Circulation 1986;74(pt 2):I82.
4. Lin FY, Hung, Yang YJ, et al: Mitral valve reconstruction with
Carpentier ring for mitral regurgitation: experience with
Chinese patients. Taiwan I Hsueh Hui Tsa Chih 1989;88:
330–5.
5. Kaplan EL, Meier P. Nonparametric estimation from incom-
plete observations. J Am Statist Assoc 1958;53:457– 81.
6. Galloway AC, Colvin SB, Baumann FG, et al. Long term
results of mitral valve reconstruction with Carpentier tech-
niques in 148 patients with mitral insufficiency. Circulation
1988;74(pt2):I97–105.
7. Duran CG, Pomar JL, Revuelta JM, et al. Conservative oper-
ation for mitral insufficiency. J Thorac Cardiovasc Surg 1980;
79:326–37.
8. Antunes MJ, Magahaes MP, Colsen PR, et al. Valvuloplasty of
rheumatic mitral valve disease. J Thorac Cardiovasc Surg
1987;94:44–56.
9. Duran CG, Revuelta JM, Gait L, et al. Stability of mitral
reconstructive surgery at 10-12 years of predominantly rheu-
matic valvular disease. Circulation 1988;78(Pt2):I91– 6.