Surgical repair of the prolapsing anterior leaflet in degenerative mitral valve disease

Background and aim of the study: Repair of the prolapsing anterior leaflet (AML) in degenerative mitral valve disease is more demanding than that of t he posterior leaflet. We reviewed our experience in the past eight years, t o examine the safety, efficacy and stability of various repair artifices. Methods: Between January 1989 and December 1997, 102 patients (mean age 64 years; range: 26-86 years) with mitral regurgitation (MR) due to prolapse o f the anterior or both mitral leaflets underwent mitral valve repair. Sixty -six patients were in NYHA class greater than or equal to III, and 94 had M R grade >II. Acute endocarditis was present in 12 patients and Barlow disea se in 16. Surgical techniques consisted of chordal shortening (n = 36), cho rdal transposition (n = 16), papillary muscle shortening or plication (n = 10), flip-over (n = 20) and artificial chordae implantation (n = 20). Results: There was no early mortality; one patient required early mitral va lve replacement (MVR) for late-appearing systolic anterior motion, and one patient benefited from a successful re-repair on day 8 for partial posterio r leaflet desinsertion. Mean follow up was 30 months (range: 3-92 months); there were four late deaths (two valve-related cerebrovascular accidents); two patients required re-repair tone after three months for prosthetic ring thrombosis, and one after 10 months for rupture of shortened chordae (corr ected by flip-over)). Five patients had MVR between four and 32 months late r: one for mitral stenosis due to posterior leaflet calcification, and four for recurrent MR due to the rupture of shortened chordae (n = 3) or plicat ed papillary muscle (n = 1). One patient suffered bacterial endocarditis wh ich was treated medically. Of the 92 remaining patients with valve repair, 81 are currently asymptomatic, five are in NYHA class II and four in class III. Transesophageal echocardiographic restudy (n = 76) at a mean of 30 mon ths after surgery revealed no MR in 68 patients, and MR of grade <II in thr ee. Conclusions: AML prolapse repair is safe, durable, and therefore can be att empted even in mildly symptomatic patients. However, chordal shortening sho uld be substituted by implantation of artificial chordae or by the flip-ove r technique.