Chordal plication and free edge remodeling for mitral anterior leaflet prolapse repair: 8-year follow-up

Repair of the anterior mitral leaflet prolapse

Repair of anterior mitral leaflet prolapse is one of the most challenging aspects in mitral valve repair surgery. In this review, we discuss the various techniques developed over the past three to four decades for the repair of anterior mitral leaflet prolapse, debate the pros and cons of each and compare their results, keeping reoperation for recurrent mitral regurgitation as the focal point of follow-up. At our center, chordal replacement with artificial expanded polytetrafluoroethylene sutures in the form of premeasured loops is the most commonly used technique for repair of anterior mitral leaflet prolapse for the past decade. We recommend and provide justification for the use of this technique, especially when mitral valve repair is performed through a minimally invasive approach. We believe that the trend towards a minimally invasive approach for mitral valve repair will exponentially increase in the next 5-10 years, at least until percutaneous techniques, if at all, become more reliable and safe.

Minimally invasive mitral valve repair for anterior leaflet prolapse

OBJECTIVE

Mitral valve repair for anterior mitral leaflet prolapse is technically challenging. We report here our experience with minimally invasive anterior mitral leaflet repair.

METHODS

Our institutional database for minimally invasive mitral valve surgery was screened for patients with mitral regurgitation caused by isolated prolapse of the anterior mitral leaflet. Patient characteristics, intraoperative data, and short- and long-term outcomes are analyzed and reported.

RESULTS

A total of 180 patients presented with mitral regurgitation caused by isolated anterior mitral leaflet prolapse. All patients underwent minimally invasive surgery at our institution between 1999 and 2010. Mitral valve repair was performed in 170 cases (94.4%), and these patients form the focus of this study. The mean age of the patients was 59.7 ± 14.8, and their mean log EuroSCORE was 4.9 ± 5.1. Mean aortic crossclamp time (cardiopulmonary bypass time) was 82 ± 25 minutes (130 ± 40 minutes). Mitral valve repair techniques were neochordal replacement with the loop technique in 68.2% of patients, chordal transfer in 14.7%, anterior mitral leaflet resection in 7.1%, and edge-to-edge repair in 5.9%. Thirty-day mortality was 1.8%. Kaplan-Meier estimates showed 86.7% ± 3.2% survival and 95.7% ± 1.6% freedom from mitral valve reoperation at 5 years.

CONCLUSIONS

This large series demonstrates good results for anterior mitral leaflet repair with the minimally invasive approach.

Surgical repair of the prolapsing anterior leaflet with chordal shortening

The purpose of this study was to review the results of mitral valve repair for prolapse of the anterior repaired with chordal shortening or shortening of the papillary muscle. Sixty three patients operated from June 1988 through June 2003, form the cohort of this study. The etiology was degenerative disease in 30 patients (47%) and rheumatic disease in 23 (37%). All patients survived the operation. Predischarge echocardiography showed no or trivial regurgitation in 61 patients (97%). Mean follow-up was 6.57 +/- 0.65 years. Twenty patients died during the follow-up for an actuarial survival of 62% at 14 years. Five patients required reoperation on the mitral valve; 88% of the patients were free from reoperation at 14 years. In conclusion, shortening plasty of the subvalvular apparatus provides good and stable results after repair of anterior leaflet prolapse.

Triangular plication of the anterior mitral leaflet: a new operative technique

This study describes the technique of triangular plication in patients with mitral valve incompetence that is due to segmental anterior leaflet prolapse. A nonabsorbable suture plicates the prolapsed leaflet area towards the ventricular aspect in a triangular fashion by decreasing the suture width towards the leaflet base. Because no leaflet tissue is resected, this technique allows for the intraoperative correction of an imperfect plication. Triangular plication was successful in all except one patient. In this patient, a failed repair was corrected with mitral valve replacement. Freedom from mitral valve incompetence of more than grade 0-I was 100% at 12 months and 86% at 36 months postoperatively.

Mitral valve replacement versus repair in 2003: where do we stand?

Mitral valve repair as a proportion of all mitral valve procedures continues to become more prominent in this country. As the procedures are performed more frequently and concomitantly surgeons become more comfortable performing these repairs, risks and benefits (compared with mitral valve replacement) have become better defined. The patient population and valve morphology that are most favorable for the repair approach have also been better defined, and new techniques (including minimally invasive approaches) have been reported. A prominent question remains: what to do about ischemic mitral regurgitation.