Mitral annuloplasty with a suture technique

We read with great interest the article of Duebener et al. [1] entitled ‘Mitral-valve repair without annuloplasty rings: results after repair of anterior leaflet versus posterior-leaflet defects using polytetrafluoroethylene sutures for chordal replacement’, and would like to congratulate for the excellent results. In recent years there has been a resurgence of the suture annuloplasty, and favorable mid-term results have been reported by a number of authors using different surgical techniques [2–4]. We introduced a suture annuloplasty for mitral valve repair as a cheap and simple alternative to ring implantation in 1992. Our technique was also a modified version of the Paneth mitral plication suture: a double-ended semicircular suture was placed in the annulus around the posterior leaflet, reinforced with pledgets at each commissure and tied at the mid-point of the posterior leaflet on a third pledget (Fig. 1) . Since 1992 to date 364 patients underwent either isolated suture annuloplasty (10%) or annuloplasty combined with mitral valve repair (90%) for various etiology (degenerative mitral valve disease: 26%, rheumatic mitral valve disease: 14%, endocarditis: 3%, secondary annular dilatation due to aortic valve disease: 25% and mitral valve disfunction due to severe coronary artery disease: 32%). Fifteen patients required mitral valve replacement for recurrent severe mitral regurgitation (4%). The actuarial survival rate and freedom from reoperation at 5 years was 86.5 and 88.2%, respectively, at the first 130 patients [5]. Initially 3-0 polypropylene (Prolene) suture was routinely used for the annuloplasty. Four of the first 50 patients developed severe mitral regurgitation within 2 years after surgery. At reoperations the repaired valves were thoroughly examined. In two cases tearing of the annuloplasty suture from the annulus was found, probably due to inadequate surgical technique in the learning curve. In the other two cases the previously placed annuloplasty suture was intact, but the Prolene suture had stretched and the annulus had redilated. Therefore 3-0 Gore–Tex suture was substituted for the mitral annuloplasty. Since its adoption in 1994 no further annuloplasty failure has occurred because of a redilated annulus. The mitral annuloplasty suture: a double semicircular suture is placed in the mitral annulus around the posterior leaflet. The suture is reinforced with pledgets at each commissure and at the centre point of the posterior leaflet. When tying the suture, the mitral annulus can be tightened to an appropriate size. Mitral plication suture is a simple, reproducible and cheap technique for mitral valve repair with acceptable mid-term results. Our findings suggest that using a strong, non-stretchable suture is mandatory for good long-term results. The polytetrafluoroethylene (Gore–Tex) fulfils the requirements as an annuloplasty suture.