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Simple And Reproducible Loop Technique For Mitral Valve Repair Using Preoperative Echocardiographic Determination
Hiroyuki Nishi, Koichi Toda, Shigeru Miyagawa, Yasushi Yoshikawa, Satsuki Fukushima, Masashi Kawamura, Daisuke Yoshioka, Tetsuya Saito, Takayoshi Ueno, Toru Kuratani, Yoshiki Sawa.
Osaka University Graduate School of Medicine, Osaka, Japan.

OBJECTIVE: Although the Gore-Tex loop technique has been widely adapted for mitral valve repair, it remains difficult to determine the appropriate length, position, and number of loops prior to surgery. We assessed our simple and reproducible method to determine appropriate loop length and number of loops required using preoperative 3D echocardiography.
METHODS: Twenty patients (males, 13; 52.8±16.6 years) underwent mitral valve repair using our strategy. We assessed the prolapse position using 3D echocardiography to select the papillary muscle for loop attachment, and the number and positions of the loops (Figure A). Then, we measured the distance between the papillary muscle tip and level of the mitral annulus (annulus height length: AH, Figure B). the loop positions were adjusted intraoperatively using a “ONE-KNOT technique”. We assessed mitral valve repair results, and preoperative AH, actual loop length (LL), and postoperative coaptation length (CL).
RESULTS: (1) Seven patients had anterior leaflet prolapse, while 5 had posterior and 8 bileaflet prolapse. The base of the loops was attached to the anterior papillary muscle in 16 and posterior in 7 patients, with the other end attached to the anterior leaflet in 7, posterior in 5, and both in 8. (2) Mean AH length and actual LL was 22.3±4.7 and 19.6±5.9 mm, respectively. LL in most cases was within -3 to +4 mm, as compared to AH. Postoperative CL was 10.2±3.7 mm. CL in patients with LL shorter than AH tended to be deeper as compared to those with LL longer than AH. (3) All mitral valve repairs were successful. Postoperative echocardiography MR grade was none in 12 and trivial in 7. LL in 1 patient with mild postoperative MR was 7 mm longer as compared to AH.

CONCLUSIONS: Using our comprehensive strategy, it was possible to perform the present simple and reproducible mitral valve method using loops. The appropriate length seemed to be 3-5 mm shorter than the distance from the papillary muscle tip to level of the mitral annulus.

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