All anterior and bileaflet mitral valve prolapses are repairable in the modern era of reconstructive surgery

Abstract

Although mitral valve repair is the preferred treatment for degenerative mitral valve disease, valve replacement still remains prevalent, particularly in the setting of anterior leaflet prolapse. We sought to determine the feasibility and mid-term durability of a lesion-based surgical strategy applied systematically in a consecutive and nonexclusionary (all comers) series of patients with degenerative mitral valve disease and either isolated anterior leaflet or bileaflet prolapse. From January 2002 to December 2010, 188 consecutive patients [mean age 56 ± 14 years (range 12-86), 31% female, mean left ventricular ejection fraction 55 ± 9%] underwent surgery for degenerative anterior mitral leaflet prolapse [isolated (n = 42, 22%) or bileaflet prolapse (n = 146, 78%)]. Degenerative aetiology was Barlow's disease in 110 (58%) patients and fibroelastic deficiency in 78 (42%). Patients with anterior leaflet prolapse were significantly more symptomatic (New York Heart Association functional Class III-IV) than those with bileaflet prolapse (28.6 vs 9.6%; P = 0.003) at the time of surgery. All patients underwent mitral valve repair and ring annuloplasty. There was 1 immediate valve replacement due to atrioventricular groove bleeding and consequent haematoma in an elderly female patient (99.5% repair rate). Predominant repair techniques were polytetrafluoroethylene neochordoplasty (or loop technique) in 93 (49%) patients, chordal transfer in 86 (46%) and posterior leaflet flip technique in 21 (11%). Median length of stay was 6 (interquartile 5-8) days. In-hospital mortality was 1% (n = 2). Predischarge transthoracic echocardiography showed none to trace mitral regurgitation in 91% of the patients and mild mitral regurgitation in 9%. The Kaplan-Meier estimates for cumulative survival at 1 and 7 years were 98.4 ± 0.9 and 88.7 ± 2.2%, respectively. Freedom from ≥ moderate mitral regurgitation was 100% at 1 year, 93.7 ± 2.2% at 4 years and 90.3 ± 3.7% at 7 years. When the interval-censored estimator was used, freedom from ≥ moderate mitral regurgitation at 1, 4 and 7 years was 100, 96 and 92%, respectively. A lesion-based surgical approach with an intention to repair all degenerative valves with anterior leaflet prolapse was applied to a consecutive series of patients with degenerative mitral valve disease. We were able to achieve a near-100% repair rate. Repair of all degenerative valves may be feasible with good mid-term durability, regardless of valve morphology, patient age or comorbidities.