Carpentier’s Reconstructive Valve Surgery

363 Pages·2011·16.23 MB·English

by  Alain Carpentier

C A R P E N T I E R ’ S
Reconstructive
Valve Surgery
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C A R P E N T I E R ’ S
Reconstructive
Valve Surgery
From Valve Analysis to Valve Reconstruction
Alain Carpentier, MD, PhD
Hon. FACC, Hon. FACS, Hon. FASA, Lasker Award
Chairman Emérite, Département de Chirurgie Cardio-Vasculaire, Hôpital Broussais, Paris
Professeur Emérite, Université de Paris Descartes
Consultant Emérite, Hôpital Européen Georges Pompidou, Paris
Assistance Publique – Hôpitaux de Paris
David H. Adams, MD
Marie-Josée and Henry R. Kravis
Professor of Cardiothoracic Surgery
Mount Sinai School of Medicine
Chairman, Department of Cardiothoracic Surgery
Mount Sinai Medical Center, New York
Farzan Filsoufi , MD
Professor of Cardiothoracic Surgery
Mount Sinai School of Medicine
Associate Chief, Adult Cardiac Surgery
Mount Sinai Medical Center, New York
Illustrations by Alain Carpentier and Marcia Williams
3251 Riverport Lane
Maryland Heights, Missouri 63043
CARPENTIER’S RECONSTRUCTIVE VALVE SURGERY ISBN: 978-0-7216-9168-8
Copyright © 2010 by Saunders, an imprint of Elsevier Inc.
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Library of Congress Cataloging-in-Publication Data
Carpentier, Alain, M.D.
Carpentier’s reconstructive valve surgery / Alain Carpentier, David H. Adams, Farzan Filsoufi ;
illustrations by Alain Carpentier and Marcia Williams.
p. ; cm.
Includes bibliographical references.
ISBN 978-0-7216-9168-8 (hardcover : alk. paper)
1. Heart valves–Surgery. I. Adams, David H. (David Harold), 1957- II. Filsoufi ,
Farzan. III. Title. IV. Title: Reconstructive valve surgery. [DNLM: 1. Mitral Valve–surgery.
2. Aortic Valve–surgery. 3. Heart Valve Diseases–surgery. 4. Reconstructive Surgical
Procedures–methods. 5. Tricuspid Valve–surgery. WG 262 C297c 2010]
RD598.C357 2010
617.4′120259–dc22
2009047672
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P R E FAC E
At the dawn of cardiac surgery in 1950, when the fi rst effectively remodel and stabilize the annulus. Whether
open-heart operations were bold surgical feats, C. Walton the shape of the ring should be systolic or diastolic was
Lillehei performed the fi rst open-heart mitral valve repair. another diffi cult consideration. Several prototypes were
He plicated the distended commissure and sutured edge tried on heart specimens: circular rings required overcor-
to edge the corresponding leafl et segments, solving the rection to achieve good leafl et coaptation, and ovoid
regurgitation. In the following years, many other tech- rings did not provide a regular line of leafl et closure.
niques were developed to correct mitral valve regurgita- Finally, kidney-shaped rings, replicating the geometry of
tion. With the exception of McGoon’s leafl et plication, a normal valve orifi ce during systole, were found to be
these techniques aimed at reducing the size of the mitral the optimal confi guration. Although the annulus was
valve orifi ce, as annular dilatation was believed to be the secured in the systolic position, the orifi ce area was always
main cause of valve regurgitation. Although early postop- adequate without even a small degree of valve stenosis,
erative results were often satisfactory, long-term results provided that the appropriate ring size was selected. In
were marred by a lack of predictability. Eventually these October 1968, the fi rst patient who benefi ted from a ring
repair techniques were progressively abandoned and annuloplasty underwent surgery at Hôpital Broussais in
replaced by prosthetic valve replacement. Paris. At that time, the only authorization required was
In 1966, as a young resident in cardiac surgery, I the approval of my mentor Professor Charles Dubost,
assisted in performing a “narrowing annuloplasty” in a who simply ensured that the materials used were labeled
16-year-old boy. This repair failed after a few months medical-quality. Ten other patients underwent successful
because of suture tearing and recurrent annular dilata- surgery. The results reported in the literature the follow-
tion. Failure can lead to the development of new concepts ing year showed a much better reliability and stability of
provided that appropriate questions are raised: What did the repair as compared to previous techniques. The
I do wrong in this patient? Why did this repair fail? Why concept of annular remodeling using prosthetic rings
have other techniques of valve repair also failed? To initiated a new era in valve repair—the era of “valve
address these questions, I undertook a methodical analy- reconstruction.”
sis of the mitral valve lesions observed during reopera- Annular dilatation is rarely the sole lesion in valve
tions. From these failed valve repairs, a common drawback regurgitation. Associated lesions involving the leafl ets
could be identifi ed: the techniques used were palliative and the subvalvular apparatus are frequent and usually
rather than reconstructive. They corrected valve regurgita- precede the annular deformation. Complementary tech-
tion by producing a certain degree of valve stenosis; they niques were therefore developed to address all pathologi-
did not restore the shape of the mitral valve orifi ce, nor cal lesions (Fig. 1). These techniques broadened the
a normal leafl et motion, nor create a large and harmoni- spectrum of reconstructive valve surgery, allowing more
ous surface of coaptation. In short, they had signifi cant complex dysfunctions to be surgically repaired. The
conceptual limitations. remodeling annuloplasty concept and complementary
One evening in November 1967, as I left Hôpital valvular reconstruction techniques were also readily
Broussais and passed under the stone arch framing the applied to the tricuspid valve. Concomitantly, a patho-
iron gates, I was struck by its similarity with the structure physiological classifi cation was introduced, which led to
of a mitral valve: the arch was the annulus; the gates were a better understanding of valvular diseases and created
the leafl ets. Their respective confi gurations and functions an instrument of communication between surgeons, car-
were complementary. Assuming that the arch or the gates diologists, and echocardiographers. While representing a
were partially destroyed, a good architect would restore small number of valve operations in the early 1970s,
their respective geometries. In particular, he would restore reconstructive valve surgery became the gold standard in
the curvature of the arch with a support structure of the the surgical treatment of mitral and tricuspid valve dis-
appropriate size and shape that would correspond to eases in our institution and worldwide.
the geometry of the gates. Obviously a surgeon should This book is not a “compendium”* of all existing tech-
do the same for the mitral valve! The concept of annular niques of valve repair. It describes a comprehensive system
remodeling emerged from this paradigm. of valve analysis and reconstructive techniques validated
Remodeling the annulus implied the creation of a in more than 10,000 patients in my institution. It pro-
prosthetic support with an optimal shape. Because the vides cardiologists and anesthesiologists with a compre-
entire annulus was involved in the deformation process, hensive description of the valve dysfunctions and the
the remodeling structure had to be a complete ring rather basic principles employed to correct them. For surgeons,
than a partial support structure. To adapt the ring to each this book provides guidelines and technical details that
individual patient, several ring sizes had to be developed.
No signifi cant deformability of the rings was required to *See Glossary.
v
vi PREFACE
400 and dedication of my assistant, Christiane Vénéziani,
Ring PM shortening Physio ring were challenged by the innumerable versions of the man-
Quadrangular resection Sliding leaflet uscript. I am especially grateful to Elsevier for the quality
Chord shortening
of the publishing, and particularly to Judith Fletcher,
300
Chord transposition
Anne Konopka, and Amy Rickles for complying with my
recommendations concerning page layout.
Finally, I express my special gratitude to Alain Deloche,
200
Jean-Noël Fabiani, Sylvain Chauvaud, John Relland,
Patrick Perier, Didier Loulmet, and Gilles Dreyfus for
providing support in periods of doubt; Jean-Pierre
100 Marino, Serban Mihaileanu, and Alain Berrebi for sharing
fibroeClaosntigce dneitfaicliency Endocarditis with me the secrets of echocardiography; and James Oury,
Albert Starr, and Lawrence Bonchek for having performed
Rheumatic Barlow Ischemic Calcified annulus
0 the fi rst remodeling annuloplasties and reconstructive
0 2 4 6 8 0 2 4 6 8 0 2 4
97 97 97 97 97 98 97 97 97 97 99 99 99 techniques in the United States. I also recognize Frank
1 1 1 1 1 1 1 1 1 1 1 1 1
Spencer, Stephen Colvin, Meredith Scott, Kevin Accola,
FIGURE 1 Development of reconstructive valve surgery at
Delos Cosgrove, Lawrence Cohn, and Randolph Chit-
Hôpital Broussais between 1970 and 1994. The development
of new techniques (upper part of the fi gure) resulted in wood in the United States as well as Manuel Antunes,
the utilization of surgery for more cases (curve) and for Carlos Duran, Robert Dion, Friedrich Mohr, Jose-Luis
more complex valvular diseases (lower part of the fi gure). Pomar, and Hugo Vanermen in Europe for having popu-
PM, papillary muscle. larized these techniques worldwide, adding their own
contributions while respecting the fundamental princi-
ples, a condition of long-term function. A special word
of gratitude goes to Judie Vivian and the 3000 members
should enable them to obtain excellent results. The dis- of Le Club Mitrale and The Heart Valve Club who, during
cussions with my co-authors, which follow each chapter, our postgraduate courses in the last 20 years, stimulated
have two aims. One is to address practical diffi culties me to share their concerns, to coin a language of com-
commonly encountered in valve reconstruction; the other munication, and to refi ne the techniques. This book will
is to discuss alternative techniques of valve repair devel- prolong our discussions, enhance our friendship, and
oped by others. We are deeply indebted to our artist, facilitate the transfer of knowledge to the young genera-
Marcia Williams, for the quality of the illustrations. She tions to come.
was able to give an artistic touch to my sketches without
compromising the anatomical precision. The patience Alain Carpentier
C O N T E N T S
SECTION I Fundamentals SECTION IV Aortic Valve Reconstruction
1. Introduction ............................................................3 20. Surgical Anatomy and Physiology .......................209
2. Valve Analysis: “The 21. Pathophysiology, Valve Analysis,
Functional Classifi cation” .......................................5 and Surgical Indications .....................................217
3. Perioperative Management ...................................11 22. Reconstructive Techniques ...................................221
4. Operative Management ........................................15
SECTION V Disease-Specifi c Approach
23. Mitral Valve Malformations ................................229
SECTION II Mitral Valve Reconstruction
24. Tricuspid Valve Malformations:
5. Surgical Anatomy and Physiology .........................27 Ebstein’s Anomaly ...............................................247
6. Pathophysiology, Preoperative Valve 25. Rheumatic Valvular Disease ...............................259
Analysis, and Surgical Indications ........................43
26. Degenerative Valvular Diseases ..........................267
7. Valve Exposure, Intraoperative Valve —Barlow’s Disease
Analysis, and Reconstruction ................................55 —Marfan’s Disease
—Fibroelastic Defi ciency
8. Techniques in Type I Dysfunction .........................63
27. Calcifi ed Annular Disease ..................................279
9. Extensive Annular Calcifi cation
and Abscesses ........................................................85 28. Infective Endocarditis .........................................285
10. Techniques in Type II 29. Ischemic Valvular Disease...................................291
Anterior Leafl et Prolapse .......................................95
30. Dilated Cardiomyopathy .....................................297
11. Techniques in Type II
31. Hypertrophic Obstructive
Posterior Leafl et Prolapse ....................................115
Cardiomyopathy ..................................................301
12. Techniques in Type II
32. Endomyocardial Fibrosis .....................................307
Commissural and Bileafl et Prolapse ....................127
33. Traumatic Valvular Injury....................................311
13. Techniques in Type IIIa:
Diastolic Restricted Leafl et Motion .....................135
34. Primary Valve Tumors.........................................315
14. Techniques in Type IIIb:
35. Immune-Mediated Valvular Diseases ..................319
Systolic Restricted Leafl et Motion .......................149
36. Carcinoid Valvular Disease .................................321
15. Techniques in Systolic Anterior
Leafl et Motion (SAM) ........................................157 37. Radiation-Induced Valvular Lesions ....................325
16. Adjunct Left Atrial Procedures ............................167 38. Medication-Induced Valvulopathy .......................329
39. Reoperations .......................................................331
SECTION III Tricuspid Valve Reconstruction
SECTION VI Transfer of Knowledge
17. Surgical Anatomy and Physiology .......................175
40. Reconstructive Valve Surgery Made Simple .........339
18. Pathophysiology, Valve Analysis,
and Surgical Indications .....................................183
Glossary ..................................................................343
19. Reconstructive Techniques ...................................193 Index ......................................................................345
vii
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S E C T I O N I
Fundamentals
1