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J Thorac Cardiovasc Surg 1997;113:957-958
© 1997 Mosby, Inc.

LETTERS TO THE EDITOR

The role of annuloplasty in mitral valve repair

Consultant Cardiothoracic Surgeon
Monash Medical Centre
246 Clayton Rd. 3168
Melbourne, Australia

Reply to the Editor:

My colleagues and I appreciate the comments of Drs. Scrofani and Santoli regarding our article and accept their appreciation of our endeavors at mitral valve repair. We wholeheartedly welcome their constructive criticism.

However, I believe that we are closer to complete agreement with them than to strong disagreement. At no stage in our article do we state than an annuloplasty is not an absolute prerequisite to achieve a successful and durable repair. What we do state is that an annuloplasty ring is not at absolute prerequisite. This statement is clearly enunciated throughout the article. Just as Drs. Scrofani and Santoli state that "stabilization of the posterior anulus with a ring or other type of support [my italics] ... is a must for mitral valvuloplasty," so too do we clearly enunciate this on page 245, paragraph 4 of the Discussion: "of the many factors contributing to successful repair, we believe the key to be stabilization of the posterior anulus by a localized annuloplasty to relieve any tension on the reconstructed leaflets."

Unlike Drs. Scrofani and Santoli, I would not call our series of 155 patients a large experience, but it does have a long follow-up, with 23 patients at 10 years. In their series of 113 cases, freedom from reoperation at 5 years is 89.7%, no confidence intervals are given, and the number of patients at risk is 22; in our series, freedom from reoperation at 10 years is 90.3% ± 4%, with 23 patients at risk.

If I may disabuse Drs. Scrofani and Santoli about our technique of restoring "annular function without any surgical procedure on the anulus," Fig. 2, B in our article clearly displays and states that 60% to 70% of the posterior mitral leaflet is excised, in essence, all of the central scallop of the posterior mitral leaflet. As such, about one third of the anulus of the posterior mitral leaflet is left without any leaflet attachments. By apposing the annular margins of the remaining leaflets, we reduce (plicate) the posterior anulus by at least 30%. As we state in the Discussion, "the placement of three to four interrupted, interlocking mattress sutures achieves this goal." The suture material is 2-0 polyester.

In essence, in our series this set of suture annuloplasties was sufficient to stabilize the posterior anulus. According to the article by Scrofani and associates, ¹ they too "plicated with interrupted stitches (2-0 polyester)" the anulus "beneath the excised or transposed portion of the mural leaflet." What they do in addition is use the pericardial strip as a belt to further reinforce the basal mural suture plication.

I believe we do not strongly disagree with Drs. Scrofani and Santoli. Rather, we believe a localized series of inexpensive suture annuloplasties is sufficient in a vast majority of cases to produce a freedom from reoperation rate of 90% at 10 years in this retrospective, hence nonrandomized series of indeterminate selectivity (as all such series are wont to be). Drs. Scrofani and Santoli believe in their innovatively clever version of an annuloplasty ring, to be added to other believers of the half dozen or more other annuloplasty rings available on the market.

12/8/79875

References

1. Scrofani R, Moriggia S, Salati M, Fundaro P, Danna P, Santoli C. Mitral valve remodeling: long-term results with posterior pericardial annuloplasty. Ann Thorac Surg 1996;61:895-9.[Abstract/Free Full Text]
   

This Article Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): John M. Alvarez Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Alvarez, J. M. Search for Related Content PubMed Articles by Alvarez, J. M.