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Replacing the Anterior Mitral Valve Leaflet With Autologous Jugular Vein in a Sheep Model  Jacques T. Janson, MMed (Thor), PhD, Andre Coetzee, MMed (Anes),

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Presentation on theme: "Replacing the Anterior Mitral Valve Leaflet With Autologous Jugular Vein in a Sheep Model  Jacques T. Janson, MMed (Thor), PhD, Andre Coetzee, MMed (Anes),"— Presentation transcript:

1 Replacing the Anterior Mitral Valve Leaflet With Autologous Jugular Vein in a Sheep Model 
Jacques T. Janson, MMed (Thor), PhD, Andre Coetzee, MMed (Anes), PhD, Gawie Rossouw, MMed (Thor), Izak Loftus, MMed (Forens Path), MMed (Anat Path), Adriaan Murray, MBChB, MMed (Anes), Pieter Rossouw, MBChB, MMed (Cardio), Philip Herbst, MBChB, MMed (Cardio)  The Annals of Thoracic Surgery  Volume 104, Issue 2, Pages (August 2017) DOI: /j.athoracsur Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions

2 Fig 1 Creating an anterior mitral valve leaflet from the internal jugular vein. (A) and (B) The left internal jugular vein is harvested. (C) The vein is cut open lengthwise, and (D) it is folded with the endothelial layer on the outside. (E) The folded vein is cut in half, and (F) the two halves are sewn together side by side. (G) The edges of the double-layered vein are oversewn, and all the branches are tied with an expanded polytetrafluoroethylene CV-8 running suture. (H) The vein leaflet is the size of a 28-mm mitral ring sizer. The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur ) Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions

3 Fig 2 Insertion of the vein leaflet. (A) The anterior leaflet with its chordae tendineae is resected 3 mm from the mitral annulus up to the commissural leaflets at both commissures. (B) The newly created vein leaflet is sutured to the anterior mitral annulus with an expanded polytetrafluoroethylene (ePTFE) CV-6 suture. (C) Six ePTFE loops (CV-5 suture) are anchored to the fibrous tip of the anterior papillary muscle with felt pledgets, and six ePTFE loops are anchored to the posterior papillary muscle to support the vein leaflet edge [11]. Interrupted ePTFE CV-5 sutures are used to attach the chordal loops to the free edge of the leaflet. (D) The valve is competent when tested with saline solution. The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur ) Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions

4 Fig 3 Survival curve and causes of mortality. (Cum = cumulative; ePTFE = expanded polytetrafluoroethylene; Postop = postoperative.) The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur ) Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions

5 Fig 4 Postoperative mitral regurgitation: echocardiographic findings.
The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur ) Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions

6 Fig 5 Echocardiogram at 6 months shows the motion of the anterior vein leaflet during the cardiac cycle. Notice the change in shape of the leaflet and how flexible the leaflet is. The valve is (A) open in diastole (arrow) and (B) closes during systole (arrow), with (C) billowing into the left atrium at the end of systole (arrow). (LA = left atrium, LV = left ventricle.) The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur ) Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions

7 Fig 6 Macroscopic findings of vein leaflets at explant. (A) and (B) Good healing of all suture lines is noted, and the expanded polytetrafluoroethylene (ePTFE) chords are covered with fibrous tissue, in this 10-month implant with good flexibility and no contracture. (C) One ePTFE chordal loop pulled loose from the leaflet edge (6.5-month implant) (red arrow). (D) This 4-month implant shows good mobility of the vein leaflet. There is partial disruption of the ePTFE chords from the leaflet edge (red arrow) and calcification on some ePTFE chords. (E) A hematoma formed between the two layers of this 1-month implant causing leaflet thickening, and the ePTFE chords pulled loose from the leaflet edge at the hematoma (red arrow). (F) A localized hematoma caused significant thickening in this 3-month implant (black arrow), and the central suture line showed partial disruption at the free edge (red arrow). The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur ) Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions

8 Fig 7 Histologic features. (A) The normal anterior mitral valve leaflet has four layers: atrialis (A), spongiosa (S), fibrosa (F) and ventricularis (V). The thickness ranges from 0.25 to 0.5 mm. (Verhoeff and Von Gieson stain; ×100.) (B) The jugular vein wall measures 0.43 mm, and the intimal cell layer is shown on the right. The media measures 0.21 mm and contains smooth muscle cells (light pink cells with blue nuclei) and elastic fibers (dark pink). The adventitia contains fibroblasts and collagen fibers. (Hematoxylin and eosin [H and E] stain; ×150.) The vein leaflet (C) implanted for 3 days shows a focal area of necrosis (asterisk). The space between the vein layers is filled with fresh fibrin (F). (H and E stain; ×40.) (C) MIB-1 (monoclonal mouse anti–human Ki-67 antigen) immunostaining on the specimen shows viable proliferating cells in the media and adventitia on day three as part of (D) the vein remodeling. There is also a complete absence of viable proliferating cells in the areas of necrosis (asterisk). (E) The organized hematoma with fibrin is a histologic section of the 3-month vein implant shown in Fig 6F. This caused vein necrosis (blue arrow) overlying the hematoma. The rest of the vein layers (V) are viable, and fibrous proliferation (asterisk) can be seen between the vein layers. The annular suture line (black arrow) and intimal fibroplasia (red arrow) are also shown. (F) This 6-month implant shows new capillaries (black arrows) running between the ePTFE sutures (S) at the annular suture line. (H and E stain; ×40.) Intimal fibroplasia (red arrows) covers the vein layers (V) on both sides with fibrovascular proliferation (asterisk) between the vein layers. (G) This is a higher magnification of the vein leaflet in (F) and shows preserved muscle fibers, myofibroblasts, collagen, and elastic fibers in the original vein wall (V) with overlying intimal fibroplasia (red arrow) and fibrous proliferation (asterisk. (H and E stain; ×100.) (H) A foreign body tissue reaction is seen around the ePTFE suture (S) with a monocyte infiltrate and formation of giant cells (red arrow). (I) ePTFE chords of a 6-month implant show fibrous proliferation around the ePTFE with collagen fibers running parallel to the chord. Dystrophic calcification (dark purple) is noted in the ePTFE suture (red arrow). (H and E stain; ×200.) The magnification given in the histologic sections is the original magnification of the slide. The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur ) Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions

9 Fig 7 Histologic features. (A) The normal anterior mitral valve leaflet has four layers: atrialis (A), spongiosa (S), fibrosa (F) and ventricularis (V). The thickness ranges from 0.25 to 0.5 mm. (Verhoeff and Von Gieson stain; ×100.) (B) The jugular vein wall measures 0.43 mm, and the intimal cell layer is shown on the right. The media measures 0.21 mm and contains smooth muscle cells (light pink cells with blue nuclei) and elastic fibers (dark pink). The adventitia contains fibroblasts and collagen fibers. (Hematoxylin and eosin [H and E] stain; ×150.) The vein leaflet (C) implanted for 3 days shows a focal area of necrosis (asterisk). The space between the vein layers is filled with fresh fibrin (F). (H and E stain; ×40.) (C) MIB-1 (monoclonal mouse anti–human Ki-67 antigen) immunostaining on the specimen shows viable proliferating cells in the media and adventitia on day three as part of (D) the vein remodeling. There is also a complete absence of viable proliferating cells in the areas of necrosis (asterisk). (E) The organized hematoma with fibrin is a histologic section of the 3-month vein implant shown in Fig 6F. This caused vein necrosis (blue arrow) overlying the hematoma. The rest of the vein layers (V) are viable, and fibrous proliferation (asterisk) can be seen between the vein layers. The annular suture line (black arrow) and intimal fibroplasia (red arrow) are also shown. (F) This 6-month implant shows new capillaries (black arrows) running between the ePTFE sutures (S) at the annular suture line. (H and E stain; ×40.) Intimal fibroplasia (red arrows) covers the vein layers (V) on both sides with fibrovascular proliferation (asterisk) between the vein layers. (G) This is a higher magnification of the vein leaflet in (F) and shows preserved muscle fibers, myofibroblasts, collagen, and elastic fibers in the original vein wall (V) with overlying intimal fibroplasia (red arrow) and fibrous proliferation (asterisk. (H and E stain; ×100.) (H) A foreign body tissue reaction is seen around the ePTFE suture (S) with a monocyte infiltrate and formation of giant cells (red arrow). (I) ePTFE chords of a 6-month implant show fibrous proliferation around the ePTFE with collagen fibers running parallel to the chord. Dystrophic calcification (dark purple) is noted in the ePTFE suture (red arrow). (H and E stain; ×200.) The magnification given in the histologic sections is the original magnification of the slide. The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur ) Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions

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