Chordal Replacement Research Articles

Image-Based Computational Fluid Dynamics to Compare Two Repair Techniques for Mitral Valve Prolapse.

OBJECTIVE: The treatment of mitral valve prolapse involves two distinct repair techniques: chordal replacement (Neochordae technique) and leaflet resection (Resection technique). However, there is still a debate in the literature about which is the optimal one. In this context, we performed an image-based computational fluid dynamic study to evaluate blood dynamics in the two surgical techniques. METHODS: We considered a healthy subject (H) and two patients (N and R) who underwent surgery for prolapse of the posterior leaflet and were operated with the Neochordae and Resection technique, respectively. Computational Fluid Dynamics (CFD) was employed with prescribed motion of the entire left heart coming from cine-MRI images, with a Large Eddy Simulation model to describe the transition to turbulence and a resistive method for managing valve dynamics. We created three different virtual scenarios where the operated mitral valves were inserted in the same left heart geometry of the healthy subject to study the differences attributed only to the two techniques. RESULTS: We compared the three scenarios by quantitatively analyzing ventricular velocity patterns and pressures, transition to turbulence, and the ventricle ability to prevent thrombi formation. From these results, we found that the operative techniques affected the ventricular blood dynamics in different ways, with variations attributed to the reduced mobility of the Resection posterior leaflet. Specifically, the Resection technique resulted in turbulent forces, related with the risk of hemolysis formation, up to 640 Pa, while the other two scenarios exhibited a maximum of 240 Pa. Moreover, in correspondence of the ventricular apex, the Resection technique reduced the areas with low velocity to 15%, whereas the healthy case and the Neochordae case maintained these areas at 30 and 48%, respectively. Our findings suggest that the Neochordae technique developed a more physiological flow with respect to the Resection technique. CONCLUSION: Resection technique gives rise to a different direction of the mitral jet during diastole increasing the ability to washout the ventricular apex preventing from thrombi formation, but at the same time it promotes turbulence formation that is associated with ventricular effort and risk of hemolysis.

Outcomes of Leaflet Resection vs Chordal Replacement for Degenerative Mitral Regurgitation

BackgroundDebate persists regarding the outcomes of leaflet resection (RESECT) vs chordal replacement (CHORD) for degenerative mitral regurgitation. Our aim was to compare early and late outcomes of the RESECT vs CHORD techniques for degenerative mitral regurgitation. MethodsA total of 1066 consecutive patients undergoing mitral repair for degenerative regurgitation with the RESECT vs CHORD techniques were evaluated from a prospectively maintained database. Propensity score matching was used to compare outcomes in RESECT vs CHORD repairs. ResultsPatients who underwent CHORD had later operative dates, more flail leaflet, and more anterior leaflet disease. With the switch to predominant use of the CHORD technique in 2010, the percentage of repair for all degenerative valves improved significantly from 83% to 91% (P = .002). A total of 467 patients were matched for baseline characteristics. Patients in the CHORD group had larger rings (34 mm vs 32 mm; P < .001) and greater use of an Alfieri stitch (66% vs 22%; P < .001) in matched patients. The 10-year survival was similar for matched patients (RESECT vs CHORD, 86% ± 3% vs 84% ± 4%; P = .5).Patients in the RESECT group had a lower 10-year cumulative incidence of mitral reoperation (RESECT vs CHORD, 1% ± 1% vs 8% ± 3%; P = .002) and severe mitral regurgitation (RESECT vs CHORD, 1% ± 1% vs 9% ± 5%; P = .05) compared with matched patients in the CHORD group. The late ejection fraction and mitral gradient were not different between the 2 groups in matched patients, respectively (P = .9 and P = .2, respectively). ConclusionsThe use of the CHORD technique for degenerative mitral regurgitation increased the repair rates, but the CHORD technique had slightly lower repair durability at 10 years compared with the RESECT technique. These results could be related to more complex disease in CHORD group.

Design and performance of double-layered artificial chordae.

Surgical repair with artificial chordae replacement has emerged as a standard treatment for mitral regurgitation. Expanded polytetrafluoroethylene (ePTFE) sutures are commonly employed as artificial chordae; however, they have certain limitations, such as potential long-term rupture and undesired material/tissue response. This study introduces a novel approach to artificial chordae design, termed the New Artificial Chordae (NAC), which incorporates a double-layered structure. The NAC comprises a multi-strand braided core composed of ultra-high molecular weight polyethylene (UHMWPE) fibers as the inner core, and an outer tube made of hydrophobic porous ePTFE. Compared to traditional ePTFE sutures, NAC exhibits increased flexibility, enhanced tensile strength, longer elongation and improved fatigue resistance. Moreover, NAC exhibits a more hydrophobic surface, which contributes to enhanced hemocompatibility. The study also includes in vivo investigations conducted on animal models to evaluate the biocompatibility and functional efficacy of the artificial chordae. These experiments demonstrate the enhanced durability and biocompatibility of the NAC, characterized by improved mechanical strength, minimal tissue response and reduced thrombus formation. These findings suggest the potential application of NAC as a prosthetic chordae replacement, offering promising prospects to address the limitations associated with current artificial chordae materials and providing novel ideas and approaches for the development of sustainable and biocompatible regenerative biomaterials.

Respect Versus Resect Approaches for Mitral Valve Repair: A Meta-Analysis of Reconstructed Time-to-Event Data

Mitral valve repair (MVr) has been associated with superior long-term survival and freedom from valve-related complications compared with mitral valve replacement for primary mitral regurgitation (MR). The 2 main approaches for MVr are chordal replacement ("respect approach") and leaflet resection ("resect approach"). We performed a systematic review and a meta-analysis using 3 search databases to compare the long-term end points between both approaches. The primary end point was long-term survival. The secondary end points were long-term MR recurrence and reoperation. After reconstruction of time-to-event data for the individual survival analysis, pooled Kaplan-Meier curves for the end points were generated. A total of 14 studies (5,565 patients) were included in the analysis. The respect approach was associated with superior survival compared with the resect approach in the overall sample (hazard ratio [HR] 0.73, 95% confidence interval [CI] 0.56 to 0.96, p=0.024, n=3,901 patients) but not in the risk-adjusted sample (HR 1.00, 95% CI 0.55 to 1.82, p=0.991, n=620 patients). There was no difference between the approaches in the rate of MR recurrence in the overall sample (HR 1.39, 95% CI 0.92 to 2.08, p=0.116, n=1,882 patients) or in the risk-adjusted sample (HR 1.62, 95% CI 0.76 to 3.47, p=0.211, n=288 patients). The data for reoperation were only available in the overall sample and did not reveal a difference (HR 0.92, 95% CI 0.62 to 1.35, p=0.663, n=3,505 patients). In conclusion, the current evidence suggests no difference in long-term mortality, MR recurrence, or reoperation between the resect and respect approaches for MVr after adjusting for patient risk factors. More long-term follow-up data are warranted.

Robotically-assisted mitral valve repair—chordal replacement with Gore-Tex loops

Robotically-assisted mitral valve repair—chordal replacement with Gore-Tex loops

A review of the development of interventional devices for mitral valve repair with the implantation of artificial chords.

Mitral regurgitation (MR) was the most common heart valve disease. Surgical repair with artificial chordal replacement had become one of the standard treatments for mitral regurgitation. Expanded polytetrafluoroethylene (ePTFE) was currently the most commonly used artificial chordae material due to its unique physicochemical and biocompatible properties. Interventional artificial chordal implantation techniques had emerged as an alternative treatment option for physicians and patients in treating mitral regurgitation. Using either a transapical or a transcatheter approach with interventional devices, a chordal replacement could be performed transcatheter in the beating heart without cardiopulmonary bypass, and the acute effect on the resolution of mitral regurgitation could be monitored in real-time by transesophageal echo imaging during the procedure. Despite the in vitro durability of the expanded polytetrafluoroethylene material, artificial chordal rupture occasionally occurred. In this article, we reviewed the development and therapeutic results of interventional devices for chordal implantation and discuss the possible clinical factors responsible for the rupture of the artificial chordal material.

What Is the Optimal Mitral Valve Repair for Isolated Posterior Leaflet Prolapse to Achieve Long-Term Durability?

Background This study assessed risk factors for mitral regurgitation (MR) recurrence or functional mitral stenosis during long-term follow-up in patients undergoing mitral valve repair for isolated posterior mitral leaflet prolapse. Methods and Results We assessed a consecutive series of 511 patients who underwent primary mitral valve repair for isolated posterior leaflet prolapse between 2001 and 2021. Annuloplasty using a partial band was selected in 86.3%. The leaflet resection technique was used in 83.0%, whereas the chordal replacement without resection was used in 14.5%. Risk factors were analyzed for MR recurrence ≥grade 2 or functional mitral stenosis with mean transmitral pressure gradient ≥5 mm Hg using a multivariable Fine-Gray regression model. The 1-, 5-, and 10-year cumulative incidence of MR ≥grade 2 was 7.8%, 22.7%, and 30.1%, respectively, whereas that of mean transmitral pressure gradient ≥5 mm Hg was 8.1%, 20.6%, and 29.3%, respectively. Risk factors for MR ≥grade 2 included chordal replacement without resection (hazard ratio [HR], 2.50, P<0.001) and larger prosthesis size (HR, 1.13, P=0.023), whereas factors for functional mitral stenosis were use of a full ring (partial band versus full ring, HR, 0.53, P=0.013), smaller prosthesis size (HR, 0.74, P<0.001), and larger body surface area (HR, 3.03, P=0.045). Both MR ≥grade 2 and mean transmitral pressure gradient ≥5 mm Hg at 1 year post surgery were significantly associated with the long-term incidence of reoperation. Conclusions Leaflet resection with a large partial band may be an optimal strategy for isolated posterior mitral valve prolapse.

Biliflet Prolapsusu Olan Hastalarda Mitral Kapak Tamirinin Postoperatif Sonuçları

Background Today, repair techniques almost completely take place of the mitral valve replacement, especially in patients with degenerative disease. Majority of the surgeons hesitate to prefer repair in patients with bileaflet prolapse. In this study we aimed to investigate postoperative results of our patients with mitral valve insufficiency due to bileaflet prolapse and treated with repair techniques Methods 89 patients who underwent mitral valve repair by the same surgical team due to bileaflet prolapse, between January 2006 and January 2016 in Turkiye Yuksek Ihtisas Hospital were included to this study. Preoperative, operative and postoperative data such as mortality, recurrent mitral insufficiency, echocardiographic parameters and reoperation rates were investigated. Results Mean follow up duration was 25.3±17.7 months. Mean age was 46.6±17.4 years. According to the transthoracic echocardiographic evaluations, 8 (9%) patients had moderate and 81 (91%) patients had severe mitral insufficiency. When preoperative and postoperative values were compared statistically significant improvement in functional capacity of patients according to NYHA classification has been noted. (2.1±0.5 ; 1, , p=0.001) Improvements in left ventricular end diastolic diameter (5.5±0.7 cm ; 5±0.6 cm, p=0.001), left ventricular end sistolic diameter (3.8±0.6 cm ; 3.6±0.6 cm, p=0.004 ), left atrium diameter (4.8±0.9 cm ; 4.3±0.6 cm, p=0.001) and pulmonary artery pressure (44.3±13.4 mmHg; 32.1±5.4 mmHg, p=0.001) were statistically significant. Conclusions In the lights of findings about good postoperative results and durability rates, mitral valve repair can be safely used in patients with mitral valve insufficiency due to bileaflet prolapse especially with chordae replacement technique which can be feasible after improvements in suture technologies.

Mitral valve repair with artificial chords: Tips and tricks.

Mitral valve regurgitation (MR) is a common valvular disorder occurring in up to 10% of the general population. Mitral valve reconstructive strategies may address any of the components, annulus, leaflets, and chords, involved in the valvular competence. The classical repair technique involves the resection of the prolapsing tissue. Chordal replacement was introduced already in the '60, but in the mid '80, some surgeons started to use expanded polytetrafluoroethylene (ePTFE) Gore-Tex sutures. In the last years, artificial chords have been used also using transcatheter approach such as NeoChord DS 1000 (Neochord) and Harpoon TSD-5. The first step is to achieve a good exposure of the papillary muscles that before approaching the implant of the artificial chords. Then, the chords are attached to the papillary muscle, with or without the use of supportive pledgets. The techniques to correctly implant artificial chords are many and might vary considerably from one center to another, but they can be summarized into three big families of suturing techniques: single, running or loop. Regardless of how to anchor to the mitral leaflet, the real challenge that many surgeons have taken on, giving rise to some very creative solutions, has been to establish an adequate length of the chords. It can be established based on anatomically healthy chords, but it is important to bear in mind that surgeons work on the mitral valve when the heart is arrested in diastole, so this length could fail to replicate the required length in the full, beating heart. Hence, some surgeons suggested techniques to overcome this problem. Herein, we aimed to describe the current use of artificial chords in real-world surgery, summarizing all the tips and tricks.

Novel Automated Suturing Technology for Minimally Invasive Mitral Chord Implantation: A Preclinical Evaluation Study.

This study evaluated the ergonomics and time requirements of using a novel automated suturing and titanium fastener deployment technology for chordal replacement in human heart specimens in open and minimally invasive cardiac surgery (MICS) simulators. Five cardiac surgeons used novel, manually powered expanded polytetrafluoroethylene (ePTFE) suturing devices to automate suture placement between mitral leaflets and papillary muscles in explanted cadaver hearts, along with customized titanium fastener delivery devices to secure suture and trim suture tails. This mitral chordal replacement test was conducted using surgical models simulating open and MICS mitral repair access. The study was approved by the institutional ethical board. After a brief introduction to this technique using plastic models, study surgeons performed 48 chordal replacements in human mitral valves, placing 18 in an open model and 30 in a right minithoracotomy model. The time range to complete a single chordal replacement was between 55 s and 8 min, with an overall mean duration of 3.6 ± 1.5 min. No difference in duration of implantation was recorded for the MICS and open sternotomy simulators used. Good control of suture delivery was reported in 95.8% (n = 46) of leaflet aspect of the sutures and in 100% (N = 48) of papillary muscle sutures. Automated mitral chordal ePTFE suturing simulated through open and MICS access demonstrated quality handling and accurate placement of sutures in human heart specimens. A clinical trial using this technology is currently ongoing. This innovation may present an important advance facilitating enhanced minimally invasive mitral valve repair.

Chordal replacement and annuloplasty in one transfemoral device for degenerative mitral regurgitation.

Chordal replacement and annuloplasty in one transfemoral device for degenerative mitral regurgitation.

Leaflet plication with neochordae implantation: A novel technique for mitral valve repair.

Leaflet plication with neochordae implantation: A novel technique for mitral valve repair.

Combination of the Modified Loop Technique and De Vega Annuloplasty in Dogs with Mitral Regurgitation.

Simple SummaryDogs, like humans, may develop valvular disease, which is particularly common in older, small-sized dogs and is one of the most common causes of canine death. Canine valvular disease generally has a good prognosis. However, approximately 30% of dogs develop congestive heart failure, particularly when the mitral valve is affected, and most dogs with severe congestive heart failure die within a year of pulmonary edema. Although cardiac surgery with extracorporeal circulation can be performed in dogs and can significantly prolong survival, the dogs’ small size is challenging from a surgical perspective, and the success rate depends on the surgeon’s skill. Mitral valve repair in dogs involves suturing cardiac tendons using polytetrafluoroethylene sutures, which are slippery and difficult to ligate at the targeted length. Moreover, the appropriate length of the artificial tendon in dogs has not been determined. The mitral annulus surrounding the mitral valve also needs to be stitched down, but the amount that should be stitched down in dogs is not known because prosthetic valve rings were not manufactured for dogs. Due to the lack of reports detailing surgical procedures in dogs, we describe in detail a surgical technique for canine mitral valve repair.Background: Detailed surgical techniques for treating canine mitral regurgitation have not been previously reported. Method: This case series included six consecutive client-owned dogs with mitral regurgitation. All dogs underwent a combined protocol, including the modified loop technique and De Vega annuloplasty (MODEL surgery), in 2021. Artificial loops covering 80% of the length of the strut chordae tendineae were used for chordal replacement. Mitral annuloplasty was subjectively performed, targeting the circumference of the septal leaflet. Results: The breeds were Chihuahua-mixed breed, Spitz, Pomeranian, Cavalier King Charles Spaniel, and Chihuahua, with average ages and weights of 11.4 ± 2.3 years and 5.49 ± 2.98 kg, respectively. The aortic cross-clamp, pumping, and surgery times were 64.0 ± 7.5 min, 168.5 ± 39.1 min, and 321.0 ± 53.1 min, respectively. After MODEL surgery, left atrial-to-aortic ratios significantly decreased from 2.20 ± 0.18 to 1.26 ± 0.22 (p < 0.01), and left ventricular end-diastolic internal diameter normalized to body weight significantly decreased from 2.03 ± 0.26 to 1.48 ± 0.20 (p < 0.01). In all cases, the clinical signs disappeared or improved significantly. Conclusions: MODEL surgery increased mitral valve coaptation, normalized heart sizes, and significantly improved clinical signs in dogs with mitral regurgitation.

Chordal Replacement With Expanded Polytetrafluoroethylene Sutures to Correct Leaflet Prolapse

In this issue of The Annals of Thoracic Surgery, Lang and associates1 from the German Heart Center in Munich have a paper on mitral valve repair for mitral regurgitation due to leaflet prolapse using exclusively chordal replacement with expanded polytetrafluoroethylene (ePTFE) sutures and mitral annuloplasty in a cohort of 346 patients followed for 10 or more years. These patients were identified from a much larger group of 807 patients who had mitral valve repair by three surgeons over 7- to 8-year interval, indicating a high volume of this type of heart valve surgery.

Beyond the 10-Year Horizon: Mitral Valve Repair Solely With Chordal Replacement and Annuloplasty

BackgroundThe long-term outcomes of mitral valve repair by nonresection techniques, such as annuloplasty and chordal replacement, for degenerative mitral valve regurgitation were investigated. MethodsAll consecutive patients with degenerative mitral regurgitation who received solely chordal replacement and annuloplasty for mitral valve repair between 2003 and 2010 at the German Heart Center Munich were reviewed. The endpoints of this retrospective study were survival, cumulative incidence of reoperation on the mitral valve, and cumulative incidence of significant recurrent mitral regurgitation. ResultsA total of 346 patients were evaluated. The median follow-up period was 10.86 (range, 0.01-15.86) years. The 30-day mortality rate was 0.58% (n = 2 of 346), whereas the 5-year survival was 92.97% ± 1.41%. At 5 years, cumulative incidence of recurrent mitral regurgitation was 6.87% ± 1.57% and cumulative incidence of reoperation on the mitral valve was 3.69% ± 1.05%. Survival at 10 years was 83.35% ± 2.15%. At 10 years, cumulative incidence of recurrent mitral regurgitation was 13.31% ± 2.22% and cumulative incidence of reoperation was 7.84% ± 1.55%. Cox regression analysis identified age, diabetes mellitus, and reduced left ventricular ejection fraction <55% as independent risk factors for death. Left ventricular ejection fraction <55% was revealed as independent risk factor for significant recurrent mitral regurgitation. ConclusionsThis study demonstrated excellent long-term outcomes with low incidence of reoperation after mitral valve repair using chordal replacement in a highly selected patient cohort. Our findings emphasized the importance of early intervention in severe degenerative mitral regurgitation, especially in patients with reduced left ventricular ejection fraction.

Mitral valve repair for extreme billowing and prolapsing valve

ObjectivesWe describe our method and results of mitral valve repair up to 20 years in a defined group of patients with mitral regurgitation caused by an extreme billowing and prolapsing valve. MethodsAn extreme billowing and prolapsing valve was defined by the presence of excess tissue on both leaflets and prolapse of 2 or more of the 3 segments of each leaflet. Among 1344 consecutive patients who underwent mitral valve repair for degenerative mitral regurgitation between 1991 and 2012 at the Sakakibara Heart Institute, 73 patients met our definition of an extreme billowing and prolapsing valve. From these 73 patients, 67 patients who underwent mitral valve repair based on the surgical strategy we developed in July 1996 were enrolled in this study. Our strategy of mitral valve repair for extreme billowing and prolapsing valves consists of (1) volume reduction of the leaflets, (2) physiologic remodeling annuloplasty for long anterior leaflet, and (3) wide usage of artificial chordae. ResultsMean age of the patients was 46.6 ± 12.9 years. There were no hospital deaths and 6 late deaths in this series. Kaplan–Meier survival at 10 years was 96.8 ± 2.2%. There were 2 reoperations. Cumulative incidence rate of mitral valve reoperation and moderate or severe mitral regurgitation at 10 years was 1.8 ± 1.8% and 11.2 ± 4.0%. Number of artificial chordal replacement was associated with decreased risk of recurrent moderate mitral regurgitation (hazard ratio, 0.60; P = .03). ConclusionsLong-term echo follow-up demonstrates good results of mitral valve repair for extreme billowing and prolapsing valves using our strategy.

A case of double‐chambered right ventricle due to cap‐like fibrous tissue and aberrant chordal insertion of tricuspid valve in adult

A double-chambered right ventricle is a rare congenital heart disease where an anomalous structure divides the right ventricle into two cavities. A 78-year-old man with dyspnea was referred to our institution for a double-chambered right ventricle (DCRV) and ventricular septal defect (VSD). Echocardiography showed normal left ventricular function, right ventricular hypertrophy, and mild tricuspid regurgitation. On parasternal short-axis views, color-flow Doppler studies showed a mosaic pattern through the stenotic right ventricular outflow tract (RVOT). Cardiac catheterization showed a 122 mmHg pressure gradient between the high-pressure chamber and the low-pressure chamber of the RVOT. Computed tomography showed a cap-like structure consisting of fibrous tissue, with moderate stenosis, which divided the right ventricle into two cavities. The aberrant tendinous chords supporting the anterior leaflet of the tricuspid valve were found inserted into the anterior wall of the RV (Figure 1). Resection of the cap-like fibrous tissue and abnormal muscle (Figure 2), detachment of aberrant tendinous chords of the tricuspid valve, closure of VSD by direct suture, and tricuspid valve plasty (TVP) were performed. TVP was achieved using an artificial chordae replacement with expanded polytetrafluoroethylene (CV-5) suture and a 32-mm Physio Tricuspid annuloplasty ring (Edwards Lifeline). Postoperative echocardiography revealed no RVOT pressure gradient and a normal right ventricular pressure of 21 mmHg. In conclusion, we report a rare case of DCRV secondary to a cap-like structure fibrous tissue with anomalous chordal insertion of a tricuspid valve leaflet.

Simple Chordal Replacement With a Newly Designed “Mitral Plate” in Mitral Valvuloplasty

Mitral valvuloplasty using GORE-TEX as the artificial chordae is often associated with difficulties in determining the length of the artificial chordae, achieving the correct artificial chordae length, and preventing knot slippage, especially for beginners. We describe a simple technique involving a novel device called the "Mitral Plate," which enables surgeons to automatically determine the correct length of the artificial chordae and tie slippery knots without performing excessive saline tests.

Predictors of safety and success in minimally invasive surgery for degenerative mitral disease.

The aim of this study was to identify predictors of periprocedural success and safety in minimally invasive mitral valve surgery and to determine the impact of pathology localization and repair technique on reoperation-free survival. We isolated 686 patients (mean age 60.5, standard deviation 12.3 years, 69.4% male) who underwent surgery for mitral valve prolapse between 2002 and 2020 in a single institution. Patients with concomitant disease, redo or mitral pathology other than degenerative mitral disease were excluded from the analysis. Periprocedural safety was defined as: freedom from perioperative death, myocardial infarction, stroke, use of extracorporeal membrane oxygenation or reoperation for bleeding. Operative success was defined as: successful primary mitral repair without conversion to replacement or to larger thoracic incisions, without residual mitral regurgitation > mild at discharge or reoperation within 30 days. Predictors for perioperative success and safety were identified using univariable and multivariable analyses. The impact of prolapse localization and repair technique on reoperation-free survival was assessed by Cox regression. The mitral repair rate and the need for concomitant tricuspid repair were 94.6% and 16.5%, respectively. Perioperative mortality occurred in 5 patients (0.7%). The criteria for perioperative safety and success were met in 646/686 (94.2%) and 648/686 (94.5%) patients, respectively. The absence of tricuspid disease requiring repair was the only independent predictor of safety in this cohort [hazard ratio (HR) 0.460 (0.225-0.941), P = 0.033]. The only independent predictor of operative success was the use of chordal replacement [0.27 (0.09-0.83), P = 0.022]. Reoperation-free survival was 98.5%, 94.5% and 86.9% at 1, 5 and 10 years, respectively. Posterior leaflet pathology demonstrated a higher reoperation-free survival as compared to other localizations (log-rank P = 0.002). The localization of leaflet pathology but not the repair method was an independent predictor for reoperation-free survival (HR 1.455, 95% confidence interval 1.098-1.930; P = 0.009). In minimally invasive mitral surgery for degenerative disease, chordal replacement yields higher rates of periprocedural success than leaflet resection. Posterior leaflet pathology is an independent predictor of reoperation-free survival.

Mitral valve repair for myxomatous mitral regurgitation; Respect or Resect

Background: The superiority of mitral repair using resection of the posterior leaflet versus neo-artificial chordea is still debatable. The objective of this study was to compare leaflet resection versus chordal replacement for mitral valve repair in patients with isolated myxomatous degeneration of the posterior mitral valve leaflet. &#x0D; Methods: This study was conducted on 199 patients with severe symptomatic mitral regurgitation due to myxomatous mitral valve degeneration. Patients were grouped into two groups: Group (1): Respect technique which included 76 patients who had limited resection of the anterior leaflet, chordal transfer, and replacement of anterior leaflet chordae by polytetrafluoroethylene sutures, and placement of annuloplasty ring. Group (2): Resect technique included 123 patients where the operation was done by resecting the prolapsed mid scallop of the posterior leaflet and placement of flexible annuloplasty ring.&#x0D; Results: There was no difference between both groups regarding gender. Patients in the Respect group were younger (37 (25th- 75th percentiles: 29- 44) vs. 54 (48- 60) years, P&lt;0.001). The minimally invasive approach was more commonly used in patients who had resection techniques (20 (26.32%) vs. 106 (86.18%); P&lt;0.001). Ischemic (99 (95- 106) vs. 79 (75- 82); P&lt;0.001) and cardiopulmonary bypass times (134.5 (130- 138.5) vs. 99 (97- 104) min; P&lt;0.001) were higher in the Respect group. Blood loss was more in the Resect group (370 (305- 390) vs. 550 (490- 600) ml; P&lt;0.001). There were no differences in the postoperative complications between groups. ICU stay was longer in patients in the Resect group (5 (5- 6) vs. 7 (6- 8) days; P&lt;0.001). Mitral valve gradient after 12 months was significantly higher in the Resect group (3 (3- 3.5) vs. 4 (3- 5) mmHg; P&lt;0.001). Mitral valve reoperation was required more in patients in the Respect group (5 (6.58%) vs. 1 (0.81%); P= 0.03).&#x0D; Conclusions: Both Respect and resect techniques for mitral valve repair had comparable outcomes and durability. The repair technique should be tailored according to the mitral valve pathology.