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New Method of Posterior Scallop Augmentation forIschemic Mitral Regurgitation
Masakazu Aoki, MD, and Toshiaki Ito, MD, PhD
Department of Cardiovascular Surgery, Matsumoto Kyoritsu Hospital, Nagano; and Department of Cardiovascular Surgery, Japanese
Red Cross Nagoya First Hospital, Nagoya, Japan

We report a new method of posterior middle scallop (P2)augmentation for ischemic mitral regurgitation to achieve
deep coaptation. First, P2 was divided straight at the centerand partially detached from the annulus in a reverse
T shape. A narrow pentagon-shaped section of pericardium
was sutured to the divided P2 and annular defect. The tip ofthe pentagon was attached directly to the papillary muscle,

thus creating a very large P2 scallop. A standard-sized ring
was placed. We adopted this technique in 2 patients withadvanced ischemic cardiomyopathy, and no mitral regurgitation was observed during a 1-year follow-up.

Rpentagon pericardium was directly attached to the dorsal
surface of the stout anterior papillary muscle using
pledget-supported Gore-Tex CV4 suture (W. L. Gore &Associates, Flagstaff, AZ). The angled cut edges of P2
were then sutured to the basal side edges of theTechnique
We applied this method in 2 male patients aged 63 and62 years. During surgery, a piece of autologous pericardium was harvested and treated with 0.6% glutaraldehyde for 10 minutes. In both patients, the mitral annulus
was dilated, and severe leaﬂet tethering was observed.
The leaﬂets and chordae were structurally intact. The P2
was cut longitudinally at the center from the free edge tothe annulus, then partially detached from the annulus
toward the lateral and medial sides in a reverse T shape.
The annular detachment was about 2.5 cm long. The
harvested pericardium was trimmed into a narrow
pentagon shape (Fig 1A). The length of the basal edge ofthe pentagon was adjusted to the length of the detachedP2 from the annulus, adding several millimeters as asuture cuff. The shoulder of the pentagon was 30% wider
than the base for the purpose of circumferential
augmentation of the coaptation zone. The length of eachbasal side edge was equal to the leaﬂet height of P2 plus
the length of the annular detachment on each side. The
upper side edges were adjusted to be 1-cm longer thanthe original P2 chordal length. The summit of theAccepted for publication Sept 29, 2014.
Address correspondence to Dr Aoki, Department of Cardiovascular Surgery, Matsumoto Kyoritsu Hospital, Nagano 390-8505, Japan; e-mail:aokim@chushin-miniren.gr.jp.

Ó 2015 by The Society of Thoracic SurgeonsPublished by Elsevier

Fig 1. (A) Glutaraldehyde-treated autologous pericardium wastrimmed into a narrow pentagon shape. A reversed T-shape incision
was made in the P2 scallop. (B) The straight edge of the pericardium
was sutured to the angled cut edges of P2. The three-dimensionallyreconstructed P2 leaﬂet bulged toward the center of the valve. Thesummit of the pericardium was directly attached to the anterior
papillary muscle (APM).
0003-4975/$36.00
http://dx.doi.org/10.1016/j.athoracsur.2014.09.080

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ecurrence of mitral regurgitation (MR) after ringannuloplastyforischemic
cardiomyopathy
frequently occurs. A recent echocardiographic study
revealed that posterior leaﬂet tethering is worsened by
restrictive ring annuloplasty [1]. Therefore, posterior
leaﬂet augmentation [2] seems to be a rational adjunct toring annuloplasty. We developed a simple method toaugment the posterior middle scallop (P2) and obtain alarge coaptation area that may effectively prevent recurrent MR.

(Ann Thorac Surg 2015;99:1087–9)
Ó 2015 by The Society of Thoracic Surgeons

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HOW TO DO IT
AOKI AND ITO
MIDDLE SCALLOP AUGMENTATION

Ann Thorac Surg
2015;99:1087–9

insufﬁcient [3, 4]. In the ﬁrst patient, the postoperative
coaptation depth decreased to 3 mm, and the coaptation
length was 14 mm (Fig 3A; Fig 3B); in the second patient,these values were 1 and 15 mm, respectively. The patients were followed up 17 and 13 months postoperatively. The last echocardiographic examination
performed 14 and 12 months postoperatively showed an
LVDd of 60 and 53 mm and an LVDs of 50 and 44 mm.
The estimated mitral valve area was 4 and 5 cm2,respectively. The MR was trivial in both patients. Bothare in New York Heart Association functional class I.

CommentFEATURE ARTICLESFig 2. Intraoperative view. The P2 scallop was enlarged with thepericardium.

pericardium with 5-0 polypropylene sutures. The angled
cut edges of P2 and the straight edges of the pericardium
conformed well because the separated P2 scallops tilted
up laterally and the pericardium was bent according tothe P2 angle (Fig 1B). Thus, the augmented P2 leaﬂetbulged toward the center of the mitral oriﬁce, creating a
deeper coaptation with the anterior leaﬂet. The original
P2 leaﬂet edge was advanced toward the apex, and thetethering was thus resolved. Finally, the basal edge ofthe pericardium was sutured to the mitral annulus.
Figure 2 shows an intraoperative photograph after patch
augmentation. A regular-sized prosthetic ring wasselected. A 32-mm Carpentier-Edwards Physio II ring
(Edwards Lifesciences, Irvine, CA) was used in 1 patient,and a 30-mm ring in the other. The ﬁrst patient underwent concomitant tricuspid annuloplasty, coronary
bypass, and left ventriculoplasty. The second patientunderwent tricuspid annuloplasty. Both patients recovered uneventfully. Preoperatively, the left ventricular
end-diastolic diameter (LVDd) was 68 and 58 mm, andthe end-systolic diameter (LVDs) was 58 and 49 mm. The
mitral valve coaptation depth [3] was 13 and 12 mm, andthe end-systolic interpapillary muscle distance [4] was
25 and 23 mm, respectively. These indices strongly
implied that annuloplasty alone would have been

Posterior leaﬂet augmentation for ischemic MR is usually
performed by placing an oval pericardium after detaching the posterior leaﬂet from the annulus between
P2 and P3 [2]. However, the P3 leaﬂet is sometimes
hypoplastic and fragile, and placement of a long sutureline between the leaﬂet and pericardial patch may
be time consuming; furthermore, only longitudinalaugmentation is obtained. We previously reported areconstruction technique using the pericardium forstructural mitral diseases [5] and applied a similar
method to ischemic MR.
We augmented the P2 scallop longitudinally and circumferentially to obtain deeper coaptation at the center ofthe valve because according to Gogoladze and colleagues[6] the coaptation length is predominantly decreased in
the A2 and P2 area in patients with functional MR. After
P2 augmentation, the mitral valve was rather bicuspidized, different from a functionally monocuspid valve
after simple annuloplasty. A standard-sized ring wasadequate in both cases and provided a sufﬁcient postoperative mitral valve area.
The coaptation length of 14 to 15 mm in our patientswas far deeper than the normal value of 5 mm in the A2and P2 region [6]. This length seemed robust enough toprotect against possible future progression of left ventricular dilatation.
Potential drawbacks of this technique are inﬂow
obstruction by a ﬂat pericardium, risk of systolic anterior
movement of the valve, and limited pericardial longevity.
Therefore, proper sizing of the pericardium and carefulfollow-up are necessary. Ischemic MR with highly

Fig 3. Postoperative long-axis view of themitral valve in (A) diastole and (B) systole(transesophageal echocardiogram). (A)Enlarged P2 scallop has an adequate valve
opening. (B) The A2 and P2 leaﬂets coapted
near the mitral annular plane, and thecoaptation was very deep.

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Ann Thorac Surg
2015;99:1087–9

HOW TO DO IT
AOKI AND ITO
MIDDLE SCALLOP AUGMENTATION

progressed left ventricular remodeling was successfullyrepaired by P2 scallop augmentation.

References
1. Kuwahara E, Otsuji Y, Iguro Y, et al. Mechanism of recurrent/
persistent ischemic/functional mitral regurgitation in the chronic
phase after surgical annuloplasty: importance of augmented
posterior leaﬂet tethering. Circulation 2006;114(Suppl 1):I529–34.
2. de Varennes B, Chaturvedi R, Sidhu S, et al. Initial results ofposterior leaﬂet extension for severe type IIIb ischemic mitral
regurgitation. Circulation 2009;119:2837–43.

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3. Calaﬁore AM, Gallina S, Di Mauro M, et al. Mitral valve
procedure in dilated cardiomyopathy: repair or replacement?
Ann Thorac Surg 2001;71:1146–52.
4. Roshanali F, Mandegar MH, Yousefnia MA, Rayatzadeh H,Alaeddini F. A prospective study of predicting factors in
ischemic mitral regurgitation recurrence after ring annuloplasty. Ann Thorac Surg 2007;84:745–9.
5. Ito T, Maekawa A, Aoki M, et al. Seamless reconstruction of
mitral leaﬂet and chordae with one piece of pericardium. Eur J
Cardiovasc Surg 2014;45:e227–32.
6. Gogoladze G, Dellis SL, Donnino R, et al. Analysis of themitral coaptation zone in normal and functional regurgitantvalves. Ann Thorac Surg 2010;89:1158–62.

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