One Hundred Percent Reparability of Degenerative Mitral Regurgitation: Intermediate-Term Results of a Dynamic Engineered Approach

Abstract

Advances in understanding dynamic mitral valve function have led to a repair technique with no leaflet resection, accurate dynamic annular and chordal sizing, and preservation of left ventricular outflow tract dynamics. This approach uses inflation of the left ventricle and ascending aorta with pressurized saline to achieve diastolic mitral valve locking and early isovolumic systole. The left ventricle is maximally dilated, the aorta and root are distended, and the mitral leaflets are opposed. This is used to adjust the length of the artificial chordae and size the fully flexible annuloplasty ring in three dimensions for accurate apposition of the zones of leaflet coaptation. We monitored 752 consecutive patients after repairs performed between 2001 and2013. There were 510 men (68.8%). Mean age was 61.3 ± 13.54 years. The leaflet repaired was anterior in 127 patients (17%), posterior in 451 (60%), both 55 (7.3%), and Barlow's in 119 (16%). Repair was isolated in 76% (573 of 752). Reparability was 100%. No prosthetic valve was implanted in patients with myxomatous or degenerative disease. Perioperative mortality was 2.3% (17 of 752) overall and was 1.6% (9 of 573) for isolated repair and 0.2% (1 of 451) for isolated posterior leaflet. Nonsignificant leaflet systolic anterior leaflet motion was observed in 0.2% (14 of 739) of patients. At 10 years, survival by Kaplan-Meier analysis was 66.4%, and freedom from reoperation was 91.8%. Freedom from significant mitral regurgitation at 5 years was 90.3%. Cox analysis showed male gender was a predictor of reoperation (p= 0.63). This dynamic approach enabled 100% reparability of myxomatous and degenerative valves with no occurrence of significant systolic anterior leaflet motion. Despite 100% of patients having been repaired, intermediate-term durability measured by reoperation rates, freedom from prosthetic valve, and intermediate echocardiographic follow-up have been good.