Semirigid posterior annuloplasty band: Reshaping the mitral orifice while preserving its physiology

摘要

Central MessageThe design characteristics of the semirigid posterior annuloplasty band are ideal for achieving a durable, physiologic mitral valve repair and allow flexibility in application.See Commentaries on pages 43 and 45. The design characteristics of the semirigid posterior annuloplasty band are ideal for achieving a durable, physiologic mitral valve repair and allow flexibility in application. See Commentaries on pages 43 and 45. When Carpentier introduced his breakthrough mitral valve (MV) reconstruction techniques in the 1970s, a key component was the placement of a rigid annuloplasty ring that would fix the MV into its kidney-shaped geometry and systolic dimensions.1Carpentier A. Cardiac valve surgery—the “French correction.”.J Thorac Cardiovasc Surg. 1983; 86: 323-337Abstract Full Text PDF PubMed Google Scholar, 2Carpentier A. Deloche A. Dauptain J. Soyer R. Blondeau P. Piwnica A. et al.A new reconstructive operation for correction of mitral and tricuspid insufficiency.J Thorac Cardiovasc Surg. 1971; 61: 1-13Abstract Full Text PDF PubMed Google Scholar, 3Carpentier A. Reconstructive valvuloplasty. A new technique of mitral valvuloplasty.Presse Med. 1969; 77 ([in French]): 251-253PubMed Google Scholar In 1978, after his initial experience with more than 200 repairs using the rigid annuloplasty ring, Duran introduced a flexible ring (Duran AnCore Annuloplasty System; Medtronic, Minneapolis, Minn).4Duran C.M. Pomar J.L. Cucchiara G. A flexible ring for atrioventricular heart valve reconstruction.J Cardiovasc Surg (Torino). 1978; 19: 417-420PubMed Google Scholar The flexible ring “corrected” MV annular dilation but did not provide fixed height/width (Ht:W) “remodeling” as advocated by Carpentier. The flexible ring, however, did allow some degree of MV annular movement throughout the cardiac cycle. In 1993, Cosgrove and colleagues5Cosgrove III, D.M. Arcidi J.M. Rodriguez L. Stewart W.J. Powell K. Thomas J.D. Initial experience with the Cosgrove-Edwards Annuloplasty System.Ann Thorac Surg. 1995; 60 (discussion 503-504): 499-503Abstract Full Text PDF PubMed Scopus (124) Google Scholar introduced a totally flexible posterior annuloplasty band, primarily for the repair of degenerative disease, which allowed movement of the anterior annulus and the subaortic curtain and restricted posterior annular dilation but due to the complete flexibility did not provide predictable Ht:W annular remodeling. Throughout the 1980s and early 1990s, the classic rigid annuloplasty ring was the most widely adopted, and although both the rigid and the various flexible rings or bands had certain useful features, they each had clear limitations to their designs. Predictable flaws in the initial unidimensional characteristics of “remodeling” versus “flexibility” can be highlighted by noting the variations and disparities in leaflet and annular size seen in patients with fibroelastic deficiency or the spectrum of Barlow's pathology. Valve leaflets can be thin or excessive, small or large, and the systolic Ht:W ratio of the annulus can range from 0.6 to 0.8 or more, depending on pathology. While the annular diastolic Ht:W ratio is typically 1.0 for most valves, the overall diameter and actual height of the annulus can vary greatly, with Barlow's valves having excess leaflet tissue and a much larger diameter, compared with valves with fibroelastic deficiency. Moreover, neither the MV diameter nor shape are fixed throughout the cardiac cycle, with the orifice diameter varying by 20% to 25% between systole and diastole and the Ht:W ratios varying from 0.6 to 1.0. These anatomic and physiologic variations indicate that the ideal annuloplasty design for mitral valve repair (MVr) must consider multiple factors and allow for a degree of flexibility in their applications. By the late 1980s, long-term results had been published demonstrating the durability of MVr in terms of freedom from reoperation or recurrent mitral insufficiency, and the superiority of va