Auto-Pericardial Mitral Valve Implantation: A Pilot Study.

INTRODUCTION: Developing nations continue to grapple with rheumatic heart disease, particularly in the young. There is a need for an alternative to prosthetic mitral valve replacement in irreparable mitral valves, which avoids the need for anticoagulation and risks of thromboembolism. METHODS: Twelve (12) patients with irreparable severe mitral valve disease underwent auto-pericardial mitral valve implantation from August 2020 to February 2021. The mitral valve leaflets were excised. Autologous pericardium treated with 0.5% glutaraldehyde for 8 minutes was fashioned into anterior and posterior mitral leaflets as per the dimensions on an indigenously designed template based on the studies by Ranganathan and Lam. The pericardial leaflets were sutured onto an appropriately sized mitral annuloplasty ring. The ring with the leaflets was implanted onto the mitral annulus. The leaflets were supported with neo-chordae prepared with Gore-Tex (W L Gore and Associates, Inc. Newark, DE, USA) and polyester sutures to mimic a repaired mitral valve in its structure and dynamics. RESULTS: The mean cross-clamp time was 138±21.7 minutes. None of the patients required re-exploration. On the third postoperative day, a mean mitral valve orifice area of 3±0.47 cm and mean mitral valve gradient of 2±1.04 were observed. None of the patients had any more than 1+ mitral regurgitation. None of them have required a re-intervention for mitral insufficiency to date. DISCUSSION: Auto-pericardial mitral valve re-implantation is a safe and effective procedure for severe, irreparable, mitral valve pathologies. However, the mid-term and long-term results need to be compared with conventional mitral valve replacement with a prosthetic valve in a randomised controlled trial.

The String Puppet Technique to Improve Exposure in Totally Endoscopic Mitral Valve Surgery.

AIM: To determine the feasibility of the string puppet technique as a flexible, dynamic alternative to atrial retractors in totally endoscopic non-robotic mitral and tricuspid valve surgeries. METHOD: Fifty-one (51) consecutive patients were operated on for totally endoscopic mitral valve repair from July 2017 to February 2018. A 3 cm peri-areolar (males) or submammary (females) incision was placed on the right chest. The thoracic cavity was accessed via the fourth intercostal space. A temporary pacing wire was placed transcutaneously as a puppeteering sling in the thoracic cavity under endoscopic vision. Multicoloured sutures were used to expose the right atrium and interatrial septum by weaving and suspending the sutures on the sling. The sling was tightened to pull up the walls of the cardia and manipulate them externally, like a puppet on a string, to improve selective exposure. RESULTS: We were able to obtain adequate exposure of the mitral and tricuspid valves in all patients without the use of atrial retractors. No patient required conversion to sternotomy due to lack of exposure. None of our patients had postoperative mitral regurgitation of more than 1+ over a mean follow-up of 2 years. CONCLUSIONS: The string puppet technique improves exposure of mitral and tricuspid valves in totally endoscopic cardiac surgery. It is safe, effective, easy to perform, and inexpensive.

Aberrant Aortopulmonary Venous Fistula: An Intraoperative Surprise.

An isolated systemic artery to pulmonary vein arteriovenous fistula is a rare clinical entity. We report a 20-year-old woman diagnosed with myxomatous mitral valve prolapse with severe mitral regurgitation and planned for mitral valve repair. An aberrant aortopulmonary venous fistula was suspected intraoperatively due to flooding of the left atrium with blood from the left inferior pulmonary vein on cardiopulmonary bypass. The mitral valve was repaired successfully. A postoperative computed tomography angiogram revealed an anomalous fistula between the descending thoracic aorta and left inferior pulmonary vein. The patient underwent successful percutaneous device closure of the fistula.