Mitral valve replacement after late failure of mitral valve repair

Abstract

M itral valve repair is the preferred surgical treatment for mitral valve dysfunction. Although the feasibility of mitral valve repair extends to 95% of patients with degenerative valvular disease and up to 75% of patients with rheumatic or ischemic valvular disease, nearly all reports describe patients who have required reoperation for recurrent mitral valve dysfunction.1-5 Late reoperation after mitral valve repair is required in 5% to 10% of patients with degenerative disease and 25% to 50% of patients with rheumatic disease.1-5 Reoperation after mitral valve repair poses specific challenges related to choice of procedure and surgical technique. Should the dysfunctional valve, which has been repaired once, be re-repaired or replaced? Except for instances of recurrent, localized degenerative disease and early technical failure (eg, suture or ring dehiscence), we favor valve replacement. How should the valve be approached? Median sternotomy with left atriotomy is our preferred approach. However, alternative strategies are useful in particular situations. Right thoracotomy may be used when patent grafts are in danger at resternotomy, and an extended transseptal incision on the heart exposes the mitral valve in the setting of a small left atrium (less than 4 cm in maximal dimension).