Modified Haircut technique for more durable mitral valve repair
Laith Tbishat, Dina FA Alwaheidi, Samim Azizi, Tamer Abdalghafoor, Hatem Sarhan, Ali Kindawi
Department of Cardiothoracic Surgery, Heart Hospital, Hamad Medical Corporation, Qatar

Introduction                                                                                     Mitral valve repair is the gold standard operation for degenerative mitral valve regurgitation, the longevity and durability of repair remains a main concern.  Multiple approaches have been proposed for Mitral valve repair with neochords implantation as well as traditional methods of leaflet resection. (1-3) A physiologic repair can maintain leaflet mobility and ensure adequate leaflet coaptation and ultimately a durable valve repair. (3,4). Adequate line of leaflet coaptation ensures optimal and durable valve function. In the respect approach, mitral leaflets are preserved, and restoration is regained with implanting artificial chordae. We present a novel technique for Mitral valve repair by providing more anatomical accuracy in inserting the Neochordae. 

 

 

Methods & Results

Patients with ruptured or lax chordae of the Posterior or Anterior mitral leaflet, and a measurements of less than 15 mm of the Posterior leaflet height were suitable for the repair.

Between January 2019 and February 2022, Suitable cases for Mitral valve repair with Modified Haircut technique were reviewed.

In 16 patients (Mean age of 50 years) there were diverse valvular pathology; Isolated flail P2 (6 patients), Isolated flail Anterior leaflet at the A2 A3 segment (5 patients) and combined A2, P2, P3 flail and prolapse (5 patients).

6 patients had isolated valve repair, 10 patients had combined procedure, CABG (n = 5), left atrial appendage closure (n = 2), tricuspid valve repair (n = 2) and one patient had congenital PFO repair.

Mean Cardiopulmonary bypass time was 134 minutes (±SD24.2), mean cross clamp time of 101 minutes (±SD18.6). One patients required further repair and two patients needed re-exploration for bleeding. All patients were discharged with smooth course of hospital stay.

 

Surgical Technique

Haircut” posterior leaflet-plasty was originally described by Chu, Michael W A et al. (5) The benefits of this technique include preserving the continuity of the annular leaflets, shortening leaflet (height reduction), reslicing sections of the flail segment and restoring leaflet support using either the original or transposed chords.

The original technique aims to reduce the posterior leaflet height to less than 15 mm by resecting excess segment height to the measured height of nearby scallops

In our technique, ruptured chordae ends are shaved with keeping the attached segment of the chordae to edges of the leaflet.

We use the chordal attachment at the papillary muscle and the edges of the leaflet as guidance for fixation points of the neochords. Instead of resection of redundant tissue we tend to fold the free edge of the leaflet for about 3-4 mm according to the height of the leaflet.  This led to more durable repair as we provide a more secure tissue and hinge at the site of chordal insertion on the leaflet.  Flexible annuloplasty ring  is used in all our mitral valve repairs

CONCLUSION

The modification of the Haircut technique is a simple & reproducible method for Mitral valve repair which is effective for repair of the posterior, anterior and bileaflet disease. It provides secure and durable repair by saving the tissues of the valve and adjustments guided by the anatomy of the patient.

REFERENCES

Perier, P. (2005). A new paradigm for the repair of posterior leaflet prolapse: respect rather than resect. Operative techniques in thoracic and cardiovascular surgery, 10(3), 180-193.

Perier P, Hohenberger W, Lakew F, Diegeler A. Prolapse of the posterior leaflet: resect or respect. Ann Cardiothorac Surg. 2015;4(3):273-277. doi:10.3978/j.issn.2225-319X.2014.11.16

Bizzarri F, Tudisco A, Ricci M, Rose D, Frati G. Different ways to repair the mitral valve with artificial chordae: a systematic review. J Cardiothorac Surg. 2010;5:22. Published 2010 Apr 8. doi:10.1186/1749-8090-5-22

Di Bacco L, Miceli A, Glauber M. Mitral Valve Repair Techniques With Neochords: When   Sizing Matters. Innovations (Phila). 2020 Jan/Feb;15(1):22-25. doi: 10.1177/1556984520901487. Epub 2020 Feb 4. PMID: 32013666.

Chu MW, Gersch KA, Rodriguez E, Nifong LW, Chitwood WR Jr. Robotic "haircut" mitral valve repair: posterior leaflet-plasty. Ann Thorac Surg. 2008;85(4):1460-1462. doi:10.1016/j.athoracsur.2007.10.040