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• W2903552011 abstract "Mitral valve repair can sometimes require leaflet augmentation or a patch repair of a defect in the leaflet. No ideal patch material is currently available that can grow and adapt to the mitral leaflet. This report describes a new technique using autologous saphenous vein as patch material. The saphenous vein is untreated, living tissue and remains flexible as a patch or leaflet augmentation for up to 3 years on echocardiography. Mitral valve repair can sometimes require leaflet augmentation or a patch repair of a defect in the leaflet. No ideal patch material is currently available that can grow and adapt to the mitral leaflet. This report describes a new technique using autologous saphenous vein as patch material. The saphenous vein is untreated, living tissue and remains flexible as a patch or leaflet augmentation for up to 3 years on echocardiography. The Video can be viewed in the online version of this article [10.1016/j.athoracsur.2018.10.062] on http://www.annalsthoracicsurgery.org. The Video can be viewed in the online version of this article [10.1016/j.athoracsur.2018.10.062] on http://www.annalsthoracicsurgery.org. There is no ideal material available to repair or reconstruct a valve leaflet. Autologous pericardium, bovine pericardium, Gore-Tex (W. L. Gore & Associates, Flagstaff, AZ) membrane, and porcine intestinal submucosa (CorMatrix, CorMatrix Cardiovascular, Roswell, GA) have all been used as patches for valvuloplasty and leaflet extension in the adult and pediatric population. Untreated autologous pericardium shrinks and retracts by thickening fibrosis [1Hisatomi K. Isomura T. Hirano A. et al.Long-term follow-up results after reconstruction of the mitral valve by leaflet advancement.Ann Thorac Surg. 1992; 54: 271-275Abstract Full Text PDF PubMed Scopus (7) Google Scholar]. Glutaraldehyde fixates the pericardium and prevents shrinkage, but it is nonviable and can still degenerate and calcify [2Shomura Y. Okada Y. Nasu M. et al.Late results of mitral valve repair with glutaraldehyde-treated autologous pericardium.Ann Thorac Surg. 2013; 95 (2000–5)Google Scholar]. Bovine pericardium degenerates with more calcification than autologous pericardium. CorMatrix causes a severe inflammatory response with eosinophilia with very few signs of remodeling [3Zaidi A.H. Nathan M. Emani S. et al.Preliminary experience with porcine intestinal submucosa (CorMatrix) for valve reconstruction in congenital heart disease: Histologic evaluation of explanted valves.J Thorac Cardiovasc Surg. 2014; 148: 2216-2225Abstract Full Text Full Text PDF PubMed Scopus (90) Google Scholar, 4Rosario-Quinones F. Magid M.S. Yau J. Pawale A. Nguyen K. Tissue reaction to porcine intestinal submucosa (CorMatrix) implants in pediatric cardiac patients: a single-center experience.Ann Thorac Surg. 2015; 99: 1373-1377Abstract Full Text Full Text PDF PubMed Scopus (57) Google Scholar]. Gore-Tex patches become covered with a fibrocollagenous layer that causes thickening and stiffness [5Turrentine M.W. McCarthy R.P. Vijay P. McConnell K.W. Brown J.W. PTFE monocusp valve reconstruction of the right ventricular outflow tract.Ann Thorac Surg. 2002; 73: 871-880Abstract Full Text Full Text PDF PubMed Scopus (76) Google Scholar]. In contrast to the patches that are currently used, the mitral valve leaflets consist of metabolically active tissue that contains extracellular fibroelastic matrix filled with valvular interstitial cells and is covered with a continuous monolayer of valvular endocardial cells [6Fenoglio J.J. Pham T.D. Wit A.L. Bassett A.L. Wagner B.M. Canine mitral complex: ultrastructure and electromechanical properties.Circ Res. 1972; 31: 417-430Crossref PubMed Scopus (77) Google Scholar]. We previously described the concept of using autologous vein to replace an anterior mitral valve leaflet in a sheep model [7Janson J.T. Coetzee A. Rossouw G. et al.Replacing the anterior mitral valve leaflet with autologous jugular vein in a sheep model.Ann Thorac Surg. 2017; 104: 584-592Abstract Full Text Full Text PDF Scopus (3) Google Scholar]. The jugular vein was harvested and used as living tissue and was supported with expanded polytetrafluoroethylene (ePTFE) chordae. The vein leaflet remained viable and functional as a mitral valve leaflet in the sheep for up to 10 months [7Janson J.T. Coetzee A. Rossouw G. et al.Replacing the anterior mitral valve leaflet with autologous jugular vein in a sheep model.Ann Thorac Surg. 2017; 104: 584-592Abstract Full Text Full Text PDF Scopus (3) Google Scholar]. The saphenous vein is metabolically active tissue lined with an endothelial cell layer and covered with a tunica media and tunica adventitia. The media contains smooth muscle cells that show similarities with the valvular interstitial cells [8Filip D.A. Radu A. Simionescu M. Interstitial cells of the heart valves possess characteristics similar to smooth muscle cells.Circ Res. 1986; 59: 310-320Crossref PubMed Scopus (208) Google Scholar]. The media and adventitia both contain collagen and elastic fibers, which give the vein strength and elasticity, features that are shared with mitral valve leaflet tissue. We describe a new technique using a patient’s own saphenous vein to reconstruct a partially destroyed anterior mitral valve leaflet in 3 patients with infective endocarditis. A 52-year-old man with known hypertension presented with moderate to severe mitral regurgitation and New York Heart Association functional class II. The patient sustained an embolic stroke with left hemiparesis that was limited to the left hand. The brain computed tomographic scan showed a small cortical infarct. His echocardiogram showed a large vegetation on the anterior mitral leaflet with prolapse of the anterior leaflet (Fig 1). Coronary angiography showed no significant coronary lesions. Enterococcus faecalis was noted on blood culture, and the patient was treated with intravenous ampicillin and gentamicin. The patient was referred for urgent mitral valve repair because of the large vegetation and mitral regurgitation. A sternotomy was performed with routine cardiopulmonary bypass, and the mitral valve was exposed through a left atrial incision in the interatrial groove. A 5-cm segment of saphenous vein was harvested from the patient’s right lower leg. A large vegetation was found on the A2 segment of the anterior leaflet edge with ruptured chordae tendineae to A2 (Fig 2A). The A2 segment with vegetation and the infected chordae were resected, but the chordae to A1 and A3 and the secondary chordae could be preserved. This procedure left a large defect in the anterior leaflet. The segment of saphenous vein was cut open along its length and sutured to the anterior leaflet with ePTFE (Gore-Tex) CV-6 suture to repair the defect (Figs 2B, 2C). The endothelial side of the vein was placed on the atrial side of the leaflet. The new leaflet edge formed by the saphenous vein was supported with Gore-Tex (CV-4) chordal loops made from CV-4 sutures. The medial half of the new A2 segment was supported by three chordal loops from the posterior papillary muscle, and the lateral half was anchored to the anterior papillary muscle by three chordal loops. The valve repair was supported with an annuloplasty ring (Medtronic CG-future 28 mm, Minneapolis, MN). The valve was competent with saline testing, and the intraoperative transesophageal echocardiogram showed a competent mitral valve with no mitral regurgitation and a good coaptation length between the segment of saphenous vein and the posterior leaflet. Histologic examination and culture of the vegetations and anterior leaflet confirmed the diagnosis of infective endocarditis from E faecalis. The patient completed a 6-week course of intravenous antibiotics in the hospital and was discharged. His left hand weakness recovered well from the embolic stroke. On last follow-up at 3 years the patient was in New York Heart Association class I, and the transthoracic echocardiogram showed no mitral regurgitation and an effective orifice area of 4 cm2. The saphenous vein segment is mobile and shows good coaptation with the posterior leaflet (Video). Two more patients had mitral valve repair with a saphenous vein, one to repair the anterior leaflet edge similar to our first patient and one to repair a posteromedial commissural defect after debridement of vegetations and infected tissue. The commissural vein patch created a new medial commissure and was supported with ePTFE chordae from the posteromedial papillary muscle. Echocardiography showed good mitral valve function with no regurgitation in both cases with 6 and 12 months of follow-up. The saphenous vein can be used to patch a defect in the mitral valve leaflet. We used the saphenous vein patches to extend the anterior mitral leaflets after the leaflets were debrided for infective endocarditis, and we supported the leaflet edges with ePTFE chordae. The saphenous vein is autologous living tissue with an intima, media, and adventitia and is strong enough to hold the ePTFE chordae and prevent regurgitation. It also remains flexible and mobile for up to 3 years on echocardiography. Long-term follow-up is needed to see whether autologous vein will remain viable and functional in the long term. eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiIzOTYyN2Y2Njc1YTc1MjdjOTBkMTM1NzVkMzljMTkxMiIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjc4NTA1NTU1fQ.d40Zd7qcKVmeZa9pDtFZ_IjMa1jBU1wC6qWRE7xvXgUV3UqAqO6EQOC8nw19Il-alzcFeykoVWjW5gieciA3Y3UGtIcQ7GQNkPLXb3Wlx3yRbQ9DGCYX6EiJ8J5zgJAiEtwEqZtRbmcG_gcAtfoNc4u9tXjRewvr-MaOcwxxui6M7aBwuGQUKqz0qJ7hf3083birrl2FGL2okBaZaTSe088QT5GQrRAYvT2neQz7ADXbqzBhq7dUZtcXUbfIFk2AIogcXzj6hRulx8dyAmm0mt6Bpfi0i_qZaipW_wkAIvgekj0paFbmR3sRUKri6Ex_Y4r6yCdx-y1iX6cwARGD0Q Download .mp4 (0.4 MB) Help with .mp4 files Video 1Echocardiography showing the movement of the saphenous vein patch and coaptation with the posterior leaflet. The expanded polytetrafluoroethylene chords that are attached to the leaflet edge and papillary muscle are also visible." @default.
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• W2903552011 date "2019-04-01" @default.
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• W2903552011 title "Reinventing the Saphenous Vein: Reconstructing the Anterior Mitral Leaflet With a Saphenous Vein" @default.
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• W2903552011 doi "https://doi.org/10.1016/j.athoracsur.2018.10.062" @default.
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