Mitral Leaflet Prolapse Research Articles

Residual Mitral Regurgitation After Repair for Posterior Leaflet Prolapse-Importance of Preoperative Anterior Leaflet Tethering.

BackgroundCarpentier's techniques for degenerative posterior mitral leaflet prolapse have been established with excellent long‐term results reported. However, residual mitral regurgitation (MR) occasionally occurs even after a straightforward repair, though the involved mechanisms are not fully understood. We sought to identify specific preoperative echocardiographic findings associated with residual MR after a posterior mitral leaflet repair.Methods and ResultsWe retrospectively studied 117 consecutive patients who underwent a primary mitral valve repair for isolated posterior mitral leaflet prolapse including a preoperative 3‐dimensional transesophageal echocardiography examination. Twelve had residual MR after the initial repair, of whom 7 required a corrective second pump run, 4 underwent conversion to mitral valve replacement, and 1 developed moderate MR within 1 month. Their preoperative parameters were compared with those of 105 patients who had an uneventful mitral valve repair. There were no hospital deaths. Multivariate analysis identified preoperative anterior mitral leaflet tethering angle as a significant predictor for residual MR (odds ratio, 6.82; 95% confidence interval, 1.8–33.8; P=0.0049). Receiver operator characteristics curve analysis revealed a cut‐off value of 24.3° (area under the curve, 0.77), indicating that anterior mitral leaflet angle predicts residual MR. In multivariate regression analysis, smaller anteroposterior mitral annular diameter (P<0.001) and lower left ventricular ejection fraction (P=0.002) were significantly associated with higher anterior mitral leaflet angle, whereas left ventricular and left atrial dimension had no significant correlation.ConclusionsAnterior mitral leaflet tethering in cases of posterior mitral leaflet prolapse has an adverse impact on early results following mitral valve repair. The findings of preoperative 3‐dimensional transesophageal echocardiography are important for consideration of a careful surgical strategy.

Minimally Invasive Mitral Valve Repair Through Right Minithoracotomy - 11-Year Single Institute Experience.

Although minimally invasive mitral valve repair (MIMVR) is increasingly being performed, only a few clinical studies from Japanese institutions have been reported.Methods and Results:From 2006 to 2017, 387 consecutive patients (135 females, mean age 56±13 years) underwent an initial isolated MIMVR through a right minithoracotomy. The mitral etiology was degenerative in 348, functional in 22, and endocarditis in 13 cases. Repair techniques included leaflet resection/plication in 280, chordal reconstruction in 109, and annuloplasty alone in 24 patients, and concomitant procedures included tricuspid valve repair and atrial fibrillation ablation in 70 (18.1%) and 78 (20.2%), respectively. Hospital mortality rate was 0.26%; 2 patients (0.5%) required intraoperative conversion to a median sternotomy. Perioperative morbidity included stroke (1.3%), reoperation for bleeding (0.8%), prolonged ventilation (0.5%), and permanent pacemaker implantation (2.1%). The transfusion rate was 14.7% and median ventilation time was 4 hours. Overall 5-year survival was 96.9%. For patients with degenerative mitral regurgitation (MR), the 5-year freedom from reoperation or severe recurrent MR, and freedom from ≥moderate MR were 94.7% and 82.2%, respectively. Repair for anterior mitral leaflet prolapse and the initial 30 cases were associated with higher occurrence of recurrent MR. MIMVR can be performed safely with low levels of mortality and morbidity, and provides sufficient repair durability. A learning curve exists in terms of repair durability, especially for anterior mitral leaflet repair.

Late right ventricular performance after mitral valve repair assessed by exercise echocardiography

ObjectivesThe aim of the study was to evaluate the right ventricular (RV) performance during exercise in patients who underwent mitral valve repair for chronic mitral valve insufficiency relative to healthy individuals and to assess exercise capacity using a semisupine ergometer.MethodsWe studied 56 patients who underwent mitral valve repair for degenerative posterior mitral leaflet prolapse between 2005 and 2014 and a control group of 13 healthy individuals. Clinical data were collected prospectively, and echocardiographic measurements of RV function were obtained at rest and at peak exercise.ResultsOne-third of the study patients had RV systolic dysfunction as indicated by tricuspid annular plane excursion (TAPSE) at rest. Resting TAPSE was lower in the study group (16.7 ± 3.3 mm) than in the control group (24.4 ± 4.3 mm), p < 0.001. TAPSE increased in both groups during exercise and exercise was shown to have a significant main effect on TAPSE F(1, 52) = 80, p < 0.001. TAPSE increased more in the control group and an interaction was detected between the participant groups (study group vs. control group) and exercise, F(1, 52) = 24, p < 0.001. In the study group, Poor postoperative RV function was associated with preoperative left ventricular dilatation but was not correlated with impaired maximum exercise capacity.ConclusionsDespite the excellent clinical outcome during rest and exercise after mitral valve repair, our results suggest patients that have undergone mitral valve repair due to posterior leaflet prolapse have significantly reduced RV function at rest and during exercise compared to healthy controls at long-term follow-up, as measured by TAPSE.

EComment. Posterior mitral valve leaflet prolapse: one term, several different meanings

eComment. Posterior mitral valve leaflet prolapse: one term, several different meanings

Mitral valve repair in Barlow's disease with bileaflet prolapse: the effect of annular stabilization on functional mitral valve leaflet prolapse.

Barlow's disease is the most severe form of degenerative mitral valve disease, commonly characterized by bileaflet prolapse. Abnormal mitral annular dynamics is typically present and results in functional prolapse of the mitral leaflets that may be addressed with annular stabilization alone. Between January 2001 and December 2015, 128 patients with Barlow's disease and bileaflet prolapse underwent valve repair. This included anterior mitral valve leaflet (AMVL) repair in 70 patients, whereas 58 patients were identified as having functional prolapse and underwent no specific AMVL repair. During the course of the study, the proportion of patients undergoing specific AMVL repair decreased (77% in the first and 33% in the second 64 patients). Semirigid ring annuloplasty was performed in all cases. The median clinical and echocardiographic follow-up duration was 6.5 years [interquartile range (IQR) 2.9-10.5 years; 93.9% complete] and 4.7 years (IQR 2.2-10.2 years; 94.4% complete), respectively. Early mortality was 1.6%. Postoperative echocardiogram demonstrated no residual mitral regurgitation in all but 1 patient (AMVL repair group). There was no significant difference in the overall survival rate at 6 years after operation between both groups. At 6 years, the freedom from recurrent ≥Grade 2+ mitral regurgitation rate was 90.7% (IQR 82.9-98.5%) and 89.1% (IQR 75.8-100%) for patients with and patients with no AMVL repair, respectively (P = 0.43). Three patients required late mitral valve reintervention, all from the AMVL repair group. Annular stabilization can effectively resolve the functional prolapse of the AMVL. Careful discrimination between functional and true AMVL prolapse allows for a technically less challenging operation that provides excellent repair durability.

Systematic review and meta-analysis of chordal replacement versus leaflet resection for posterior mitral leaflet prolapse

ObjectivesTo compare outcomes of chordal replacement versus leaflet resection techniques for repair of isolated posterior mitral leaflet prolapse. MethodsWe searched MEDLINE and EMBASE databases for studies that compared chordal replacement (“neo-chord” group) versus leaflet resection (“resection” group) techniques for the treatment of posterior mitral leaflet prolapse. Data were extracted by 2 independent investigators and subjected to a meta-analysis using a random-effects model. ResultsOne randomized controlled trial (RCT), 1 propensity-matched study, and 6 unadjusted observational studies, with a total of 1926 patients, met our inclusion criteria. Two studies reported only perioperative outcomes; mean follow-up ranged from 1.0 to 5.9 years in the remaining studies. In pooled data from unadjusted observational studies, annuloplasty ring diameter was higher in the neo-chord group (+1.5 mm; P = .0003), but with high heterogeneity (I2 = 91%). Based on limited data, postprocedural left ventricular ejection fraction may be greater in the neo-chord group, but this difference reached statistical significance only in the RCT (+3.4%; P = .03), and not in 2 observational studies that reported this outcome (+2.7%; P = .10). There was no difference in recurrent mitral regurgitation at follow-up between the resection and neo-chord groups; however, patients in the neo-chord group had a lower rate of mitral valve reoperation at follow-up in the unadjusted observational studies (incidence rate ratio, 0.22; P = .0008 [I2 = 0%; 4 studies, 1331 patients]). ConclusionsChordal replacement may be associated with greater freedom from reoperation and may lead to improved postoperative left ventricular function compared with leaflet resection. However, these conclusions are supported primarily by data from unadjusted observational studies, and high-quality RCTs of chordal replacement versus leaflet resection are needed.

Possibilities of Echocardiography at the Stages of Surgical Treatment of the Patient with the Mitral Valve Posterior Leaflet Prolapse Resulted in Mitral Insufficiency and Atrial Fibrillation (A Case Report)

The mitral valve prolapse is characterized by the degeneration of the valve leaflets, accompanied by their thickening, increasing surface area and flexibility. The mitral valves leaflets bulge (prolapse) beyond the plane of the atrioventricular ring into the left atrium during ventricular systole and lose the ability to close tightly, leading to the mitral regurgitation. Acute chord rupture of the mitral valve posterior leaflet is a rare but important cause of severe mitral regurgitation and the development of acute or progressive chronic heart failure. Acute mitral insufficiency, accompanied by hemodynamic disorders, requires an urgent valve plastic surgery or valve prosthetics. The mitral valve plastic surgery gives a number of undeniable advantages over prosthetics, providing the best hemodynamic parameters, saving the patient from lifelong receiving of anticoagulant drugs. Detailed qualified echocardiographic evaluation of all structures of the mitral valve (fibrous ring, MV leaflets by segments, overlapping structures, structure of the chordal apparatus, papillary muscles) provides the necessary information for the mitral valve reconstructive plastic surgery with the choice of the method that is most optimal for a certain patient at the preoperative stage. We report herein a clinical observation of the patient with a diagnosis: acquired heart disease, the mitral valve posterior leaflet prolapse with mitral insufficiency Grade 3. Chronic heart failure IIA. II FC. Atrial fibrillation. The patient underwent multicomponent mitral valve reconstruction with the creation of a neochord and the fibrous ring plastic on the duplicate of a PTFE strip (soft support ring), pairwise isolation of the pulmonary vein entrance and right cavotricuspid isthmus.

Some health aspects of children born with different types of intrauterine growth restriction during the early neonatal period

Aim. To evaluate some health aspects of children born with different types of intrauterine growth restriction during the early neonatal period.Methods. Clinical and anamnestic, physical, laboratory, electrophysiological, ultrasound and statistical methods were used. Children’s past medical history, development during early neonatal period, physical development, functioning of autonomic nervous system and cardiovascular system were assessed.Results. It was revealed that development of different types of intrauterine growth restriction is related to father and mother’s age at the time of pregnancy, women’s body mass before pregnancy, and time of pregnancy complication development (abortion risk, pre-eclampsia, arterial hypertension, Rh-immunization, edema). Fetuses with asymmetric type of intrauterine growth retardation had survived hypoxia more often (by 4.87 times). Children with symmetrical type of intrauterine growth retardation were more often born by C-section (by 2.66 times), with smaller anthropometric measurements, with more frequent and severe hypotrophy, moderate and severe cerebral ischemia and mild intracranial hemorrhage, cryptorchidism, kidney diseases, atrial septal defects, muscular ventricular septal defects, open arterial duct, and depleted reserves. Children with asymmetric type of intrauterine growth retardation more often had hypoglycemia, jaundice, polycythemia, restricted adaptation reserves, myocardial metabolic disorders, anterior mitral valve leaflet prolapse, posthypoxic changes similar to hypertrophic cardiopathy.Conclusion. Revealed features of past medical history, development during early neonatal period of life, physical development, functioning of autonomic nervous system and cardiovascular system in different types of children’s intrauterine growth restriction can promote formulation of criteria for early diagnosis of adaptive and reserve disorders and identification of dispensary groups.

Assessment of Mitral Valve Repair With Exercise Echocardiography: Artificial Chordae vs Leaflet Resection

Mitral valve (MV) repair with artificial chordae (AC) or leaflet resection (LR) is associated with good hemodynamics at rest. The aim of this study was to compare these techniques in terms of exercise capacity and echocardiographic parameters of hemodynamics at rest and peak exercise. We conducted a study in 2015 of 56 patients, who had undergone surgery for degenerative posterior mitral leaflet prolapse between 2005 and 2014 using either AC (n = 24) or LR (n = 32). Clinical data were collected, exercise capacity was measured, and resting echocardiography and peak exercise echocardiography were performed. No significant differences were detected among groups regarding exercise duration or peak exercise workload measured in Watts (W) (AC: 136 ± 43 W and LR: 131 ± 40 W; P = 0.65). The mean mitral gradient at rest was 3.0 ± 1.3 mm Hg in the AC group and 3.0 ± 1.0 mm Hg in the LR group (P = 0.90). The mean MV gradients at peak exercise did not differ significantly between groups (AC: 8.3 ± 3.4 and LR: 11.3 ± 8.7; P = 0.19). Four patients (17%) in the AC group and 1 (3%) in the LR group had systolic anterior motion, P = 0.15. We conclude that both methods of posterior MV leaflet repair were associated with good hemodynamics at rest and peak exercise. The groups had comparable exercise capacity. MV pressure gradients at rest and peak exercise were similar in both groups.

Rheumatic Giant Left Atrium—An Overview

Aim: To present the aneurysmal dilatation of left atrium due to rheumatic mitral valve disease and its clinical consequences such as arrhythmic, thromboembolic and compressive manifestations. Introduction: Extreme enlargement of left atrium, usually referred to as giant, gigantic or aneurysmal dilatation is an uncommon finding with a reported incidence of 0.3% in rheumatic heart disease. It is an important clinical risk identifier to predict the outcome of cardiovascular disease. Case reports: Aneurysmal left atrium correlating with the length of pure mitral regurgitation jet in a 18-year-old girl, posterior mitral leaflet prolapse with regurgitation jet swirling around the entire interatrial septum in a 37-year-old male, Giant left atrium in mixed mitral valve disease in a 37-year-old female and a thrombosed giant left atrium resembling as “coconut” in a 50-year-old female were reported. Conclusion: Giant left atrium may be misinterpreted as right-sided pleural effusion, pericardial effusion and mediastinal tumor on X-ray chest and so echocardiographic evaluation is mandatory to exclude the aneurysmal left atrium in such conditions.

Transapical off-pump mitral valve repair. First experience with the NeoChord system in Poland (report of two cases)

Artificial chord implantation to repair a flail or prolapsing mitral valve leaflet requires open heart surgery and cardiopulmonary bypass. Transapical off-pump artificial chordae implantation is a new surgical technique proposed to treat degenerative mitral valve regurgitation. The procedure is performed using the NeoChord DS1000 system (NeoChord, Inc., St. Louis Park, MN, USA), which facilitates both implantation and lenght adjustment of the artificial chordae under two (2D)- and three (3D)-dimensional transoesophageal echocardiographic (TEE) guidance on a beating heart. Two male patients aged 60 and 55 years with severe mitral regurgitation due to posterior leaflet prolapse underwent transapical off-pump artificial chordae implantation on September 3, 2015. The procedure was performed by left minithoracotomy under general anaesthesia in a cardiac surgical theatre, using 2D and 3D TEE guidance. Early procedural success as confirmed by 3D TEE was achieved in both patients, with implantation of 6 artificial chordae in the first patient and 3 artificial chordae in the second patient. Both procedures were uneventful, and no postoperative complications were noted. The patients were discharged home on the 8th and 6th postoperative day, respectively. The NeoChord DS1000 system allows both implantation and lenght adjustment of artificial chordae under 2D and 3D TEE guidance on a beating heart. Our initial experience in 2 patients with posterior mitral leaflet prolapse indicates that the procedure is feasible and safe.

Infective Endocarditis With the Billowing Mitral Leaflet Syndrome

SESSION TITLE: Global Case Report Poster - Miscellaneous SESSION TYPE: Global Case Report Poster PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM INTRODUCTION: Billowing mitral leaflet syndrome, one of the degenerative mitral valve diseases, is the cause of mitral regurgitation. Valvular heart disease predispose to infective endocarditis. In this case, bulky and redundant mitral leaflets of the billowing mitral leaflet syndrome became misunderstood as sessile vegetation. CASE PRESENTATION: A 52-year-old Japanease man presented with a 1-month history of fever, general malaise, edema of legs and low back pain. He had no significant medical history. We performed transthoracic echocardiography, and detected sessile vegetations, below 10mm in size, on the posterior mitral valve leaflets (P2) and anterior mitral valve leaflet (A2). In addition, echocardiography showed a mitral severe regurgitation caused by the posterior mitral valve leaflet (P2) prolapse. A definitive blood culture revealed the presence of streptococci mutans. Based on the above findings, we diagnosed infective endocarditis with relatively large sessile vegetation. The patient was started on a 2-week course of intravenous antibiotics, benzylpenicillin + gentamicin after Sulbactam / Ampicillin + gentamicin. But clinical response was not good, persistent sessile vegetation and constant high C-reactive protein level. Thereby, we planned mitral valve operation. Surgery was performed with cardiopulmonary bypass and mild hypothermia after achievement of general anesthesia. There was no sessile vegetation that pointed by preoperative echocardiography, but mitral valve leaflets were billowing with excess tissue. In addition, there were granular vegetations on bi-mitral valve leaflets, and P2 chordae was ruptured. Hence, infected bi-Mitral valve were resected, we operated mitral valve replacement by a mechanical valve. Ampicillin was administered for 6-weeks after surgery. Control of infection after operation was satisfactory. The patient discharged hospital on 42-days after surgery. DISCUSSION: Degenerative mitral regurgitation such as billowing mitral leaflet syndrome is the most frequent etiology for severe mitral regurgitation. mitral regurgitation has the potential for causing infective endocarditis. In this case, an excess of myxomatous mitral tissue, characteristic of billowing mitral leaflet syndrome, was diagnosed with sessile vegetation, because he had no significant valvular disease history, systolic murmur or heart failure. CONCLUSIONS: In summary, we have reported infective endocarditis with the billowing mitral leaflet syndrome. An excess of myxomatous mitral tissue was misjudged sessile vegetations. Reference #1: Br Heart J. 1975 Mar;37(3):326-30. Infective endocarditis in the billowing mitral leaflet syndrome. Lachman AS, Bramwell-Jones DM, Lakier JB, Pocock WA, Barlow JB. DISCLOSURE: The following authors have nothing to disclose: Ayako Nagasawa No Product/Research Disclosure Information

The Premature Ventricular Contraction-Induced Mitral Valvular Cardiomyopathy Successfully Treated by Radiofrequency Ablation: A Case Report

[Case report] A 70-year-old man referred to our hospital because he suffered from New York Heart Association (NYHA) functional class 2 heart failure symptoms. The electrocardiogram showed frequent monomorphic premature ventricular contractions (PVCs). The echocardiogram showed moderate mitral regurgitation (MR) due to anterior mitral leaflet (AML) prolapse with reduced left ventricular ejection fraction (LVEF)of 48%. Coronary angiography showed 99% stenosis in right coronary artery and 75% stenosis in left anterior descending artery. First, we conducted percutaneous coronary intervention because he refused surgical therapy. Although complete revascularization was achieved, PVCs were not disappeared and heart failure (HF) was not improved. Next, we conducted simultaneous lidocaine challenge test and left ventriculogram showing PVC disappearance and accompanying MR improvement in Sellers classification of 2 from 3. We considered that PVCs caused both HF and MR. PVCs were disappeared and improved MR to 2 from 3. The radiofrequency ablation (RFA) was conducted, and PVCs, which arose from aorto-mitral continuity, was successfully ablated at earliest activation site. PVCs have not recurred after RFA resulting continuous MR improvement and LVEF normalization. He spends free from HF symptoms for 14 months.[Conclusion] We report a rare case of mitral valvular cardiomyopathy, in which both reduced LVEF and moderate AML prolapsing MR were successfully treated by PVC ablation.

0117: Left ventricular mechanics in mitral valve prolapse: a longitudinal strain study

Valve apparatus alterations may influence left ventricular (LV) mechanics in mitral valve prolapse (MVP). To assess LV mechanics and ventriculo-valvular interaction in MVP. A comprehensive echocardiography including 2D speckle tracking myocardial longitudinal strain assessment was carried out in 194 adult patients with MVP (leaflet displacement >2mm above the annulus) and 30 matched controls. In MVP group mitral regurgitation (MR) was not significant in 76 (39%) patients (NoMR-MVP, effective regurgitant orifice <10mm 2 ), mild to moderate in 53 (27%) and severe in 65 (34%) patients. Posterior (PML) and/or anterior (AML) mitral leaflet prolapse were present in 188 (93%) and 85 (42%) patients, respectively. PML and AML positions averaged –6.0±3.4mm and –1.6±3.5mm, respectively. Ventriculo-atrial disjunction was found in 82 (41%) patients and averaged 5.7±1.6mm. Posterior wall thickening was clearly increased in MVP groups with frank wall bulging in 82 patients (41%). Despite the third left chamber (between mitral annulus and prolapsed leaflets) forward stroke volume was preserved in MVP groups, and even increased in NoMR-MVP (44±9mL/m 2 vs 39±9mL/m 2 in Controls, p<0.001). In addition LV EF was improved in NoMR-MVP. Global Longitudinal Strain (GLS) was also improved in NoMR-MVP (–21.5±2.8%) and in the overall MVP group (–21.7±3.0%) compared with Controls (–19.7±1.7%, both P<0.001). In multivariate analysis GLS improvement was associated with the magnitude of PML prolapse (β=0.14, P=0.04), posterior wall thickening (β=–0.16, P=0.004), posterior papillary muscle displacement in systole (β=–0.21, P=0.002) and posterior wall bulging (β=–0.23, P<0.001). MVP and associated abnormalities have a significant impact on LV mechanics. LV systolic function is improved in MVP as assessed by EF and GLS and preserves forward stroke volume. These changes might have significant effect at long-term on LV myocardium.

Predictive factors of long-term results following valve repair in ischemic mitral valve prolapse

BackgroundIn patients with ischemic mitral regurgitation, leaflet prolapse requires an accurate evaluation since surgical approach depends on valvular and subvalvular characteristics. This study aims to describe a cohort of patients over a long-term follow up, analyzing survival, reoperation and predictive factors of surgical outcomes. Methods and resultsFrom March 1994 to June 2011, 75 patients with ischemic mitral regurgitation and leaflet prolapse underwent surgical myocardial revascularization and mitral valve repair (90.7%) or replacement (9.3%). Our cohort was followed up until April 2015, with a mean follow up of 7±3years.Cardiac-related deaths occurred in 26 patients, with a mean survival of 114.2months, including eight patients with in-hospital mortality. Reoperation was performed in 14 patients, due to valve repair failure. Twenty-six patients experienced moderate-to-severe mitral regurgitation. A preoperative LVEDD>62mm, LVESD>52mm, previous anteroseptal myocardial infarction, diffuse coronary artery disease, papillary anatomy type 1, partial rupture of the papillary muscle, A1-A2 scallop prolapse and postoperative mitral valve configuration (tenting area, tenting height, alfa-1 angle and alfa-2 angle) were identified as independent predictors of poor outcome. An index quantifying the stress on the annulus imparted by annuloplasty was elaborated and predicted endpoints. ConclusionLeaflet prolapse is an important entity in patients with ischemic mitral regurgitation, and its pathogenic mechanism mostly relies on papillary muscle lesion or elongation. Perioperative parameters describing geometric features of left ventricle, valvular and subvalvular components should be considered to provide a tailored approach for mitral valve repair, or to opt for immediate replacement in case of unfavorable geometry.

Left ventricular performance early after repair for posterior mitral leaflet prolapse: Chordal replacement versus leaflet resection

ObjectiveTo review hemodynamic performance early after valve repair with chordal replacement versus leaflet resection for posterior mitral leaflet prolapse. MethodsBetween April 2006 and September 2014, 72 consecutive patients underwent valve repair with chordal replacement (30 patients) or leaflet resection (42 patients) for isolated posterior mitral leaflet prolapse. Left ventricular ejection fraction, end-systolic elastance, effective arterial elastance, and ventricular efficiency were noninvasively measured by echocardiography and analyzed preoperatively and ∼ 1 month postoperatively. Mitral valve repair was accomplished in all patients, and no regurgitation (including trivial) was observed postoperatively. ResultsChordal replacement resulted in significantly less reduction in left ventricular ejection fraction, and significantly greater increase in end-systolic elastance than leaflet resection (left ventricular ejection fraction, 4.8% vs 16.7% relative decrease [P = .005] and end-systolic elastance, 19.0% vs −1.3% relative increase [P = .012]). Despite comparable preoperative ventricular efficiency between the groups, the postoperative ventricular efficiency in the chordal replacement group was superior to that in the leaflet resection group (ventriculoarterial coupling, 32.0% vs 89.3% relative increase [P = .007] and ratio of stroke work to pressure-volume area, 4.3% vs 13.4% relative decrease [P = .008]). In multivariate analysis, operative technique was a significant determinant of left ventricular ejection fraction and ratio of stroke work to pressure-volume area (P = .030 and P = .030, respectively). ConclusionsChordal replacement might provide patients undergoing valve repair for posterior mitral leaflet prolapse with better postoperative ventricular performance than leaflet resection. Longer follow-up is required to compare long-term outcomes.

Long term outcomes of posterior leaflet folding valvuloplasty for mitral valve regurgitation.

Posterior mitral valve leaflet prolapse due to degenerative mitral valve disease has been treated with tissue sparing repair techniques since 2002. The simplified foldoplasty technique effectively lowers the height of the redundant posterior leaflet and creates an optimal coaptation line for the anterior leaflet that results in excellent long term durability, freedom from reoperation, and return of functional status. Patient demographics and in-hospital outcome data were extracted from electronic medical records of 229 patients, aged 60.6±13.7 years who underwent the procedure for mitral valve repair (MVR) involving the posterior leaflet from myxomatous disease between 2002 and 2014. Parametric analyses were performed on outcomes data, while long-term survival was assessed by Kaplan-Meier analyses. Concomitant coronary bypass surgery was performed on 32/229 (14%) patients, the mean perfusion time was 119±40 min, and the mean cross clamp time was 86±31 min. Post-operative mortality was 2/229 (0.9%), reoperation for bleeding occurred in 4 (1.7%) and postoperative stroke in 4 (1.7%) patients. Long term follow up rate was 100% and the mean study follow-up duration was 6.8±2.3 years. Overall late mortality rate was 24/229 (14.9%), and mitral valve re-intervention was performed on 7 patients (4.3%). NYHA class III/IV and clinically significant MR at follow up were significantly lower compared to preoperative values (both P<0.001). Our results encourage further use of this simple and effective technique in patients with isolated posterior leaflet prolapse.

Análisis comparativo de los resultados del uso de neocuerdas frente a la resección de velo posterior en la cirugía reparadora de la insuficiencia mitral degenerativa

Introduction and objectivesThere is a lack of studies comparing the results of both techniques in MV repair procedures for correction of posterior leaflet prolapse in degenerative mitral regurgitation and most of what has been published analyses the short term postoperative course.The present study was carried out to evaluate results of mitral valve repair surgery with quadrangular resection or neochordae implantation in degenerative posterior leaflet prolapse, with a special emphasis in postoperative leaflet coaptation analysis using the coaptation length index. Methods98 patients were included in this study if they presented degenerative posterior leaflet prolapse as the main cause of mitral regurgitation, and received quadrangular resection or neochordae implantation for its correction. We compared clinical and echocardiographic follow-up data between both techniques. ResultsPerioperatively, there were no differences in surgical times, size of ring employed, risk of systolic anterior motion and residual intraoperative mitral regurgitation. During follow-up, there were no differences in clinical course or echocardiographic examination, except for the left ventricle end-dyastolic diameter, which had a statistically better regression in the resection sample (–12.3±8.7 vs –8.1±8.5mm, P<.05). The coaptation analysis was similar for both groups (coaptation length index: 0.25±0.15 for resection group vs 0.2±0.07 for neochordae, P=.08). ConclusionsOur results demonstrate that neochordae implantation technique for degenerative posterior mitral leaflet prolapse correction offers similar mid-term clinical and echocardiographic outcomes compared to quadrangular resection technique, including the grade of leaflet coaptation.

Strain balance of papillary muscles as a prerequisite for successful mitral valve repair in patients with mitral valve prolapse due to fibroelastic deficiency

The aim of this study was to assess the papillary muscle strain as a contributor to recurrent mitral regurgitation (MR) after mitral valve repair for fibroelastic deficiency. Sixty-four patients with isolated posterior mitral valve prolapse and severe MR referred for surgery were prospectively recruited between 2008 and 2012. Two- and three-dimensional echocardiography and speckle tracking were performed in all patients. The longitudinal strain of the anterolateral (AL) and posteromedial (PM) papillary muscles was individually calculated as well as the global longitudinal strain of both papillary muscles was measured before and after mitral repair and normalized to left ventricle end-diastolic volume. Eight patients (12.5%) had at least moderate MR 6 months after mitral repair. The longitudinal strain of the AL (preop -4.94 ± 2.2 vs. postop -3.28 ± 1.3, P < 0.001) and the PM papillary muscles (preop -12.64 ± 5.3 vs. postop -4.12 ± 6.77, P < 0.001) as well as the global strain of both papillary muscles (preop -7.59 ± 3.48 vs. postop -1.07 ± 6, P < 0.001) were all reduced after surgical repair. The longitudinal strain of the PM papillary muscle was the strongest predictor of recurrent MR (when less than or equal to -14.78). The global preoperative papillary muscle strain was also a determinant of recurrent MR when the global strain was greater than -9.05% (area under the curve: 0.895, sensitivity: 100%, and specificity: 76.8%). Patients with isolated posterior mitral leaflet prolapse are less likely having any residual MR post repair when the global papillary muscle strain of both papillary muscles is close or equal to zero. Strain of the papillary muscles may be an important determinant in predicting residual MR in patients who undergo mitral valve repair.

An alternative "no resection" technique for posterior mitral leaflet prolapse repair: reverse T-plasty.

Reverse T-plasty is an alternative "no resection" technique for posterior mitral leaflet prolapse repair that is inspired by butterfly resection. It combines mediolateral and anteroposterior plane foldings of the posterior leaflet without any resection and shortens cardiopulmonary bypass and cross-clamping time.