Double Valve Repair for Marfan Aortic Root Aneurysm and Bileaflet (Barlow’s) Mitral Valve

<p><strong>Objectives</strong></p><p>Repair of simultaneous complex aortic and mitral valve defects in patients with Marfan syndrome can be difficult. This video illustrates a double valve repair using two remodeling annuloplasty rings, as a technical simplification for simultaneous reconstruction.</p><p> </p><p><strong>Video Summary</strong></p><p>Risk-adjusted outcomes of multiple valve procedures may be better with repair than with prosthetic valve replacement (1, 2). The patient in this video was a 38-year-old woman with Marfan syndrome, along with aortic root aneurysm and severe aortic and mitral valve insufficiency. Echocardiography showed bileaflet mitral valve (MV) prolapse with multiple jets, consistent with a Barlow’s valve. A trileaflet aortic valve (AV) had severe insufficiency with a posterior jet. The aortic annulus and sinus measured 23 mm and 50 mm, respectively, and the sinotubular junction was 33 mm. On inspection, the MV appeared myxomatous with primarily prolapsing posterior segments. Two pairs of 2-0 polytetrafluoroethylene chords were secured in the anterior and posterior papillary muscles and then stuffed into the ventricle. After placement of a large mitral annuloplasty ring, the chords were retrieved from the left ventricle, and they were attached to the left and right prolapsing posterior leaflet segments using a weaving technique (3, 4). Each chord was tied to the proper length during final valve testing (an “adjustable” chordal replacement). A small posterior leaflet cleft also was closed, and a water test confirmed a competent mitral valve.</p><p>The trileaflet AV was inspected and the leaflets appeared normal. A 23 Hagar dilator confirmed the echocardiographic annular measurement. Using ball leaflet sizers, a 21 mm ring was chosen for the aortic annuloplasty. The ring was implanted by first burying the three commissural posts into the subcommissural triangles using three mattress sutures. The ring was lowered below the valve, and two annular looping sutures were passed around each sinus aspect. After tying all nine sutures, good leaflet coaptation was achieved. Because the left coronary sinus was normal, only the right and noncoronary sinuses were replaced with two tongues of a remodeling graft, and the right coronary button was reimplanted. The distal aortic anastomosis was completed, and the aorta was unclamped. The transesophageal echocardiogram showed a competent MV and mild AV insufficiency, and the patient recovered uneventfully.</p><p><strong>Conclusion</strong></p><p>Simultaneous AV and MV annuloplasty with remodeling geometric rings simplifies simultaneous repair of Marfan aortic and mitral insufficiency. This approach could facilitate aortic valve repair in this setting.</p><p><strong>References</strong></p><ol><li>Rankin JS, Thourani VH, Suri RM, et al. Associations between valve repair and reduced operative mortality in 21,056 mitral/tricuspid double valve procedures. <em><a href="https://doi.org/10.1093/ejcts/ezt077">Eur J Cardiothorac Surg. 2013;44(3):472-477</a></em>.</li><li>Vohra HA, Whistance RN, Hechadi J, et al. Long-term outcomes of concomitant aortic and mitral valve repair. <em><a href="https://doi.org/10.1016/j.jtcvs.2013.10.016">J Thorac Cardiovasc Surg. 2014;148(2):454-460</a></em>.</li><li>Rankin JS, Orozco RE, Rodgers TL, Alfery DD, Glower DD. “Adjustable” artificial chordal replacement for repair of mitral valve prolapse. <em><a href="https://doi.org/10.1016/j.athoracsur.2005.01.042">Ann Thorac Surg. 2006;81(4):1526-1528</a></em>.</li><li>Rankin JS. Mitral valve repair for Barlow’s syndrome using adjustable artificial chordal replacement. CTSNet, Inc. <a href="http://www.ctsnet.org/article/mitral-valve-repair-barlow’s-syndrome-using-adjustable-artificial-chordal-replacement">http://www.ctsnet.org/article/mitral-valve-repair-barlow’s-syndrome-using-adjustable-artificial-chordal-replacement</a>. Published June 27, 2010. Accessed July 23, 2018.</li></ol><p>Dr Rankin is a consultant for BioStable Science and Engineering, Inc, in Austin, Texas. BioStable Science and Engineering provided support for this video.</p>

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