Simple Endocardial Running Suture Technique for Concealing Prosthetic
Material in Mitral Valve Annulus Cerclage to Prevent HemolysisINTRODUCTION
Hemolytic anemia following mitral valve replacement (MVR) is a rare condition, occurring in < 1% of the cases[1-3]. The most recognized contributor to this condition involves a regurgitant jet colliding with the valvular apparatus, which, in MVR, includes prosthetic materials such as pericardial strips, prosthetic rings, and protruding suture materials[2,4]. Early case reports of hemolysis following suture repair of the mitral valve are available in the literature and illustrate this scenario[5-7].
Reintervention, whether by re-repair or valve replacement, must be a safe and effective approach for relieving hemolysis. However, later reports of hemolytic anemia in patients with annuloplasty revealed poor endothelization of the ring, primarily caused by residual regurgitant jets. Early postoperative regurgitation prevents proper endothelization of annuloplasty rings and predisposes to hemolytic anemia[7,8] (Figure 1C).
Endocardial running suture technique for concealing prosthetic material in mitral valve plasty. (A) Mitral annuloplasty: partial running suture and completed suture. (B) Intraoperative view of a mitral plasty with a bovine pericardial strip. (C) Necropsy specimen showing non-endothelialized prosthetic material. (D) Schematic views illustrating the endocardial running suture on the mitral valve annulus.
At our institution, hemolysis following MVR occurred in two pediatric patients. Other potential causes were excluded, and the condition was attributed to the prosthetic material used in the annulus. One patient required ferrous sulfate supplements, while the other needed surgical intervention, which involved replacing the Teflon™ felt with a piece of bovine pericardium[7].
Previous studies have discussed strategies to mitigate the adverse effects of prosthetic material in MVR. Salvador et al.[9] introduced the use of an autologous pericardial strip as an alternative to bovine pericardium. The evidence of prosthetic material contributing to hemolysis and our experience with these two cases motivated us to explore new approaches to prevent this condition. We hypothesized that concealing prosthetic material in mitral valvuloplasty could reduce red cell injury, preventing hemolysis. In addition, this technique could also potentially reduce the risk of thrombosis. The aim of this brief communication is to introduce, for the first time, the concept of a suture technique that invaginates prosthetic material, potentially reducing the undesirable effects previously discussed.
The Technique
After completing the annuloplasty, an invaginating running suture is placed along the entire length of the annuloplasty, plicating the endocardial tissue to cover the prosthetic material (Figure 1).
COMMENTS
To our knowledge, the literature does not contain any previous presentations of this concept. It is not intended to replace the original MVR technique; it serves to inspire the exploration of alternative approaches for specific scenarios, particularly in patients requiring reoperation because of hemolysis following MVR. We believe it is worthwhile sharing the technical details because the concept is straightforward and safe, does not involve the introduction of additional foreign material, and adds no significant time to the surgery conceptual technique.
We have presented the original concept of a running suture technique designed to conceal prosthetic material and prevent hemolysis.
ACKNOWLEDGMENTS
The authors would like to acknowledge the use of Grammarly and ChatGPT-4.0 for providing language and grammar support during the final revision of this manuscript.
-
No financial support.
-
This study was carried out at the Department of Surgery and Anatomy, Division of Cardiovascular and Thoracic Surgery, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, São Paulo, Brazil.
REFERENCES
-
1Acharya D, McGiffin DC. Hemolysis after mitral valve repair. J Card
Surg. 2013;28(2):129-32. doi:10.1111/jocs.12060.
» https://doi.org/10.1111/jocs.12060 - 2Abourjaili G, Torbey E, Alsaghir T, Olkovski Y, Costantino T. Hemolytic anemia following mitral valve repair: a case presentation and literature review. Exp Clin Cardiol. 2012;17(4):248-50.
-
3Pomerantzeff PM, de Almeida Brandão CM, Albuquerque JM, Pomerantzeff
PY, Takeda F, Oliveira SA. Mitral valve annuloplasty with a bovine pericardial
strip--18-year results. Clinics (Sao Paulo). 2005;60(4):305-10.
doi:10.1590/s1807-59322005000400008.
» https://doi.org/10.1590/s1807-59322005000400008 -
4Nasso G, Di Bari N, Santarpino G, Moscarelli M, Siro Brigiani M,
Condello I, et al. Long-term outcomes of pericardial strip versus prosthetic
ring annuloplasty for secondary tricuspid regurgitation by a minimally invasive
approach. J Cardiothorac Surg. 2021;16(1):338.
doi:10.1186/s13019-021-01723-4.
» https://doi.org/10.1186/s13019-021-01723-4 -
5Lam BK, Cosgrove DM, Bhudia SK, Gillinov AM. Hemolysis after mitral
valve repair: mechanisms and treatment. Ann Thorac Surg. 2004;77(1):191-5.
doi:10.1016/s0003-4975(03)01455-3.
» https://doi.org/10.1016/s0003-4975(03)01455-3 -
6Yeo TC, Freeman WK, Schaff HV, Orszulak TA. Mechanisms of hemolysis
after mitral valve repair: assessment by serial echocardiography. J Am Coll
Cardiol. 1998;32(3):717-23. doi:10.1016/s0735-1097(98)00294-0.
» https://doi.org/10.1016/s0735-1097(98)00294-0 - 7Moreira Neto FF, Evora PR, Ribeiro PJ, Scarborough RN, de Freitas JN. Anemia hemolítica após cirurgia reparadora da insuficiência valvar mitral em crianças. Arq Bras Cardiol. 1990;55(1):55-8.
-
8Al Zeer S, Dalbeni A, Pozzani L, Lechi A, Delva P. Severe haemolytic
anaemia after valvuloplasty and annuloplasty. BMJ Case Rep.
2010;2010:bcr0920081022. doi:10.1136/bcr.09.2008.1022.
» https://doi.org/10.1136/bcr.09.2008.1022 - 9Salvador L, Cavarretta E, Minniti G, Di Angelantonio E, Salandin V, Frati G, et al. Autologous pericardium annuloplasty: a "physiological" mitral valve repair. J Cardiovasc Surg (Torino). 2014;55(6):831-9.
