Mital valve regurgitation with anterior mitral leaflet chordal rupture or elongation —Repair using the flip over technique—

Repair of prolapsed anterior mitral leaflet has remained technically difficult. The purpose of this study was to assess the clinical results after using the flip-over technique for patients with anterior mitral leaflet prolapse due to dhordal rupture or elongation. Between January 1993 and September 1997, fifteen adult patients with pure mitral valve regurgitation (MR) due to prolapse of the anterior mitral leaflet underwent repair using the flip-over technique. The indication for this procedure were; 1) all mitral structures except the prolapsed area must appear to be intact, and 2) the corresponding chordae attached to the posterior leaflet should be sufficiently strong to be transferred to the anterior leaflet. The prognoses following this technique were retrospectively studied to assess the early and mid-term clinical outcome of this procedure. Follow up was complete in all patients and ranged from 2 to 56 months (with a mean of 25 ± 17.9 months). There was no hospital death, None required reoperation. One patient died because of acute recurrent MR during follow-up. No other complication was experienced. Doppler echocardiographic studies at the final follow-up showed less than mild regurgitation in 11 (78.6%) of the 14 surviving patients. We believe that this procedure was effective for that the obtained repair of a prolapsed anterior mitral valve and early and mid-term clinical outcome from this procedure has been satisfactory.     

Leaflet resection for the degenerative mitral valve regurgitation; early/long-term assessment

Leaflet resection for posterior leaflet prolapse has been a standard repair procedure with good longterm durability. The aim of this study was to review our experience of mitral valve repair, in which resection of the anterior and/or posterior leaflets was performed. Between October 1991 and December 2010, 172 patients with degenerative mitral valve regurgitation underwent mitral valve reconstruction,including 98 patients with the posterior leaflet prolapse, 47 patients with the anterior leaflet prolapse, 17 patients with both leaflets and 10 patients with the commissure prolapse. Most patients in this study were supposed to be caused by fibroelastic deficiency and we have not experienced systolic anterior motion after repair. The mean follow-up period was 8.7 ± 5.5 years. The freedom from reoperation rates at 15 years in 88.7 ± 5.3% of the anterior leaflet procedure, 96.6 ± 2.5% of the posterior leaflet, and 100% of both leaflets. The results of resection of a diseased prolapsed mitral leaflet have been promising so far. However, reoperation was required in 7 patients (4.1%) and reoperation rate was higher in patients with anterior prolapse and longer follow-up will evaluate precisely be benefit.     

The "hybrid flip-over" technique for anterior leaflet prolapse repair

Repair of the anterior mitral leaflet or bi-leaflet prolapse is technically more demanding than repair of the posterior mitral leaflet. Although several techniques have been proposed for the repair of anterior mitral leaflet prolapse during bi-leaflet repair, practical challenges remain, including the determination of the appropriate length for artificial chords. Herein we describe a novel and reproducible technique for bi-leaflet mitral valve repair, including those with extensive anterior mitral leaflet prolapse.     

Chordal transfer for repair of anterior leaflet prolapse

A variety of techniques have been developed for repair of prolapse of the anterior leaflet of the mitral valve. At The Cleveland Clinic Foundation, we favor chordal transfer for this entity. In most instances, normal chordae with a strip of leaflet tissue are transferred from the posterior leaflet to the free edge of the unsupported anterior leaflet; the posterior leaflet is repaired in standard fashion employed for quadrangular resection. In selected cases, chordal transfer is accomplished by transfer of secondary anterior leaflet chordae to the unsupported free edge. Because normal chordae are used in both instances, there is no need for measurement of chordae or judgment of their length. With this technique for correction of anterior leaflet prolapse, 5-year freedom from reoperation after mitral valve repair is 96%.     

Repair of aortic leaflet prolapse: the "sliding leaflet technique"

Valve-preserving aortic replacement has become an accepted therapeutic option for aortic dilatation with normal valve leaflets. The presence of a leaflet prolapse often induces the choice of a composite graft repair. In these cases, however, the repair of a leaflet prolapse is possible and represents a valuable alternative to a prosthetic valve. The conventional techniques of repair of a cusp prolapse are designed to restore coaptation through a reduction of free margin length. The sliding leaflet technique is an alternative procedure conceived to repair the prolapsed valve cusp by remodeling both the free margin and the annular insertion.     

Anterior mitral leaflet prolapse as a primary cause of pure rheumatic mitral insufficiency

BACKGROUND: This study was designed to revise the mechanisms and repair techniques of anterior mitral leaflet prolapse observed during the correction of pure rheumatic mitral regurgitation in children. METHODS: From March 1993 to May 1998, 36 children suffering from pure rheumatic mitral regurgitation due to anterior leaflet prolapse underwent mitral valve repair. The mean age was 12.5 years (range, 6 to 16 years). Anterior leaflet prolapse was due to chordal elongation in 25 patients (group A), chordal rupture in 6 patients (group B), and retraction of anterior secondary chordae tendineae, creating a V-shaped deformity in the middle of the anterior leaflet, thus moving the free edge of the anterior leaflet away from the coaptation plane, in 5 patients (group C). Chordal shortening, transposition, and resection of anterior secondary chordae tendineae were used to correct anterior leaflet prolapse according to the predominantly responsible mechanism. RESULTS: All patients were available for clinical follow-up, which ranged from 6 months to 5 years (mean follow-up, 3 years). Echocardiographic studies were obtained until the 3rd postoperative month, and all patients showed significant improvement in their left ventricular and atrial dimensions. There was one late death related to endocarditis. Two patients in group C who had mitral valve repair underwent mitral valve replacement on the 19th and 24th postoperative months, respectively, because of failure of mitral valve repair. CONCLUSIONS: Mitral valve repair for pure mitral regurgitation due to rheumatic anterior leaflet prolapse can be performed safely for all types of mechanisms. Although the techniques we used provide stable short-term results in each of these groups, midterm results are better in groups A and B, where tissue thickening is less important, recurrences of rheumatic carditis are lower, and the interval between the first rheumatic attack and the surgical procedure is shorter than in group C.     

Chordal plication and free edge remodeling for mitral anterior leaflet prolapse repair: 8-year follow-up.

BACKGROUND: Chordal suture plication and free edge remodeling represent a personal technique for the repair of anterior leaflet prolapse. We report the results of an 8-year experience. METHODS: Sixty-one patients with degenerative mitral regurgitation caused by prolapse of the anterior leaflet (11) or both leaflets (50) underwent anterior leaflet prolapse repair. Twenty patients who had associated cardiac procedures are included. RESULTS: There were two perioperative deaths. Postoperative mitral regurgitation fell to 0.4 +/- 0.7 versus 3.7 +/- 0.4 preoperative (p < 0.0001). Mean follow-up was 40.5 months. There were 3 late deaths and 3 mitral reoperations (1 of 3 repairs, 2 of 3 replacements). Thromboembolism and endocarditis occurred in 1 patient each. Actuarial overall survival, freedom from cardiac death, and freedom from mitral reoperation at 92 months were 85.1% +/- 7.9%, 88.9% +/- 7.7%, and 94.6% +/- 3.0%, respectively. CONCLUSIONS: Our technique of anterior leaflet prolapse repair appears effective, safe, and durable at mid- to long-term follow-up, and may be used in the presence of extensive disease of both leaflets.     

Leaflet folding plasty for mitral valve repair

Objectives: Leaflet folding plasty was introduced for avoiding systolic anterior motion and coronary artery injury after mitral valve repair. We report the application and early outcome of this technique for mitral valve regurgitation. Methods: From January 1997 to January 2004,16 patients with mitral valve regurgitation were operated on using leaflet folding plasty. The group comprised 9 men and 7 women, with a mean age of 61.6 years. There were 15 patients with degenerative and 1 with ischemic mitral valve disease. The causes of mitral regurgitation were posterior mitral leaflet prolapse in 11 patients and commissural prolapse in 5 patients. Results: Mitral valve reconstruction could be performed in all patients. There were no perioperative deaths. Postoperative mitral regurgitation fell to 0.13±0.52 compared with 3.6±0.51 preoperatively. Systolic anterior leaflet motion was not observed in any patients after the procedure. The mean follow-up period was 22 months. There were no late deaths and reoperation was not required during follow-up. Conclusions: Early outcome of leaflet folding plasty for mitral valve repair was satisfactory. This technique may have advantages to accomplish mitral valve repair safely in patients with mitral regurgitation due to posterior or commissural prolapse.     

Mitral valve repair for anterior leaflet prolapse: surgical techniques review and 16-year follow-up results

Abstract   Objective: Mitral valve repair is now the surgical treatment of choice for mitral regurgitation. However, the repair of anterior leaflet prolapse due to chordal rupture or elongation remains a technically challenging procedure. Here, we review our experience and present the long-term results of mitral valve repair for mitral regurgitation due to anterior leaflet prolapse. Methods: Between January 1988 and August 2006, 210 patients with mitral regurgitation underwent mitral valve reconstruction. We performed mitral valve repair in 49 patients with mitral regurgitation due to anterior leaflet prolapse. The preoperative degree of mitral regurgitation was moderate to severe in all patients. There were 36 patients (73.5%) with degenerative, eight (16.3%) with infective endocarditis, and five (10.2%) with rheumatic. Reconstructive techniques included chordal replacement in 13 patients, chordal shortening in 14, chordal transposition in five, chordal shortening and reinforcement with artificial chordae in four, leaflet folding plasty in six, and resection-suture in four. Results: Follow-up was complete with an average of 89 ± 59 months (range 1–201 months). In the early postoperative period, transthoracic echocardiography was performed in all patients. The grade of regurgitation was trivial (Grade I) in 17 patients (34.7%) and mild (Grade II) in seven patients (14.3%). Survival rate at 10 and 15 years was 95.2% and 88.9%, respectively. Freedom from reoperation at 10 and 15 years was 95.8% and 89.0%, respectively. Conclusions: The long-term results of mitral valve repair for anterior leaflet prolapse are satisfactory, with low mortality and morbidity. In particular, chordal replacement using temporary Alfieri stitch is a simple and effective procedure.     

Anterior leaflet resection of the mitral valve

Triangular resection is a reconstructive option for treatment of anterior leaflet mitral disease with segmental prolapse. In our experience, it is a safe and reproducible technique, associated with low rates of recurrent MR or need for reoperation, as well as decreased likelihood for systolic anterior motion after mitral repair. We review our experience with this technique over a 25-year experience with mitral valve reconstruction.     

Surgical techniques for the repair of anterior mitral leaflet prolapse

Myxomatous disease is the leading cause of mitral valve regurgitation in the developed world. Although posterior mitral leaflet (PML) prolapse is the most common cause of regurgitation and of repair, lesions of the anterior mitral leaflet (AML) are often considered beyond the possibilities of repair. The surgical anatomy and pathology of the AML and a precise terminology for the location of the lesions are described. The surgical maneuvers for commissural prolapse, chordal shortening, chordal replacement, leaflet resection, and annuloplasty are also described. The advantages and limitations of each maneuver are discussed. It is concluded that a flexible approach to the repair of the AML is necessary to adapt the best technique for each type of lesion. No particular technique can be applied systematically to all lesions. It is the author's contention that the majority of AML lesions can be repaired safely.     

Correction of anterior mitral prolapse. Results of chordal transposition.

From 1986 to 1992 102 mitral valve repairs were done for mitral regurgitation due to a degenerative disease. Forty-eight patients had an anterior prolapse or prolapse of both leaflets at initial presentation and underwent chordal transposition from the mural leaflet to the anterior leaflet. The corrective procedure was completed by polytetrafluoroethylene or pericardial posterior annuloplasty. Operative mortality was 2.9%, and follow-up (average 22 months) was 100% complete. There were three postreconstruction valve replacements (one earlier and two later) for a probability of freedom from reoperation of 91.5% +/- 5.2% at 3 years. Freedom from all morbidity was 85.5% +/- 5.5% at 3 years. Postoperative echocardiographic studies demonstrated a good mitral valve function: (1) Eighty-seven percent of patients presented no or mild residual regurgitation; (2) transmitral flow indexes were within the norm; (3) left ventricular outflow tract flow was normal in all patients. This study shows that chordal transposition is a safe and effective technique for prolapse of anterior or both leaflets and improves the chances of repair in patients with mitral degenerative disease.     

Triangular plication of the anterior mitral leaflet: a new operative technique

This study describes the technique of triangular plication in patients with mitral valve incompetence that is due to segmental anterior leaflet prolapse. A nonabsorbable suture plicates the prolapsed leaflet area towards the ventricular aspect in a triangular fashion by decreasing the suture width towards the leaflet base. Because no leaflet tissue is resected, this technique allows for the intraoperative correction of an imperfect plication. Triangular plication was successful in all except one patient. In this patient, a failed repair was corrected with mitral valve replacement. Freedom from mitral valve incompetence of more than grade 0-I was 100% at 12 months and 86% at 36 months postoperatively.     

Leaflet folding plasty combined with annular plication for mitral valve repair

We describe a new technique of mitral valve repair based on two reconstructive techniques: (1) the folding leaflet method, and (2) the classic annular plication. This combination appears to be useful in cases with a large prolapsing posterior mitral leaflet with excessive leaflet height or in cases with commissural prolapse involving both the anterior and posterior leaflets.     

Mitral valve repair for broad, asymmetrical prolapse in the posterior mitral leaflet

We designed a mitral valve repair and successfully performed this repair for a case of broad, asymmetrical prolapse in the middle scallop of the posterior mitral leaflet. The repair procedure consists of making a fan-shaped leaflet by resecting the prolapsed portion in a trapezoid shape with detachment of the leaflet along the annulus and leaflet reapproximation by rotating this fan-shaped leaflet. This technique can utilize more leaflet tissue for filling the gap made by leaflet resection than the quadrangular resection and suture technique. As a result, it helps reduce tension on the suture lines, avoids the need for extensive annular plication, and also avoids leaflet distortion while making it easier to adjust the height of the leaflets that should be reapproximated. The essence of this mitral valve repair exists in the “resecting line of the leaflet,” which has not yet been reported.     

Edge to edge repair for mitral regurgitation in a patient with chronic hemodialysis: report of a case

In a patient with chronic hemodialysis, the high risk of calcific degeneration of biological prosthetic valve and anticoagulant related complications after valve replacement have been reported. A 71-year-old woman with hemodialysis underwent the edge to edge repair combined with ring-annuloplasty for mitral regurgitation caused by the anterior leaflet prolapse without any torn chordae. Postoperative course was uneventful. There was no significant mitral regurgitation. Double mitral orifices were confirmed by the postoperative echocardiography. A calculated functional mitral valve area was 3.06 cm2. The edge to edge repair is a simplified technique and carried out in a short time. We believe the edge to edge repair is a useful technique for anterior mitral valve prolapse in a patient with chronic hemodialysis.     

Systolic anterior motion of the mitral valve despite the sliding leaflet technique for repair of the mitral valve

We report a systolic anterior motion of the anterior mitral leaflet despite employing the sliding leaflet technique for repair of mitral valve regurgitation. A 65-year-old man with chronic, symptomatic mitral regurgitation due to ruptured chordae tendineae underwent mitral valve repair by quadrangular resection of the posterior leaflet and sliding leaflet technique with ring annuloplasty. After weaning from cardiopulmonary bypass, left ventricular outflow obstruction developed and transesophageal echocardiography demonstrated systolic anterior motion of the mitral valve and severe mitral regurgitation. Non-operative treatment resolved the outflow tract obstruction, systolic anterior motion and mitral regurgitation. We conclude that post-repair systolic anterior motion can still occur after the sliding plasty procedure and that medical treatment can successfully resolve systolic anterior motion and outflow tract obstruction in most patients.     

Surgical repair of mitral valve prolapse through a minimal right vertical infraaxillary thoracotomy

Abstract Background: Minimally invasive mitral valve surgery has been proven a safe and cosmetic alternative to the conventional median sternotomy approach. The aim of this study is to retrospectively evaluate the clinical outcome of mitral valve repair for leaflet prolapse through a minimal right vertical infraaxillary thoracotomy (RVIAT). Methods: From January 2003 to December 2011, 68 patients with mitral regurgitation (MR) due to leaflet prolapse underwent mitral valve repair through a RVIAT approach. There were 37 males and 31 females. The mean age of the patients was 37.8 ± 10.5 years. Of the 68 patients, 45 had posterior leaflet prolapse and 23 had anterior leaflet prolapse. Results: The mean incision length was 7.3 ± 1.8 cm (range 5.5 to 10.0 cm). Mitral valve repair technique included quadrangular resection with or without sliding repair (40 cases), edge to edge technique (six cases), artificial chordae (18 cases), chordal transfer (four cases), and ring annuloplasty was performed in all 68 patients. There was no severe morbidity and operative mortality. Echocardiography after operation demonstrated absence or trivial mitral regurgitation in 52 patients and mild regurgitation in 16 patients. During the 3 months ～8 years' follow-up period, one patient (1.5%) underwent mitral valve replacement through the median sternotomy due to recurrent severe MR. Other patients were in good condition. Conclusion: Surgical repair of mitral valve prolapse can be successfully performed through the RVIAT approach achieving excellent cosmetic and clinical results. (J Card Surg 2012;27:533-537).     

An effective technique to correct anterior mitral leaflet prolapse

Up to one-third of the patients with degenerative mitral valve disease and severe mitral regurgitation have anterior mitral valve prolapse due to chordal rupture or elongation. Surgical treatment of such a condition is often technically demanding and not infrequently associated with suboptimal results. Techniques used to treat anterior leaflet prolapse include chordal transfer, chordal shortening, artificial chordae, and anterior leaflet resection or plication. Each of these strategies has potential shortcomings, and there is considerable controversy concerning the durability of anterior leaflet prolapse repairs using these techniques. The "edge-to-edge" technique, a simple and effective method of correcting anterior mitral leaflet prolapse is described.     

Treatment of ruptured or elongated anterior mitral valve chordae by partial transposition of the posterior leaflet: experience with 29 patients

We report a series of 29 patients, 5 to 75 years of age (mean age, 31.8 +/- 21.4 [SD] years), with pure mitral regurgitation caused by ruptured or elongated chordae of the anterior mitral leaflet. These patients underwent mitral valve repair by segmental transposition of the posterior leaflet with its attached chordae sutured to the free edge of the flail anterior leaflet. There were 2 hospital deaths. Follow-up ranged from 1 to 35 months (mean follow-up, 14.9 +/- 8.5 months). One patient is lost to follow-up. Two patients are in New York Heart Association Functional Class II; all others are in Class I. In 17 patients there is no detectable murmur; in 5 patients a mild to moderate systolic murmur can be detected, while 4 have a marked systolic murmur. The adequacy of the repair could be confirmed by Doppler echocardiography, which has shown no evidence of prolapse in 22 patients. A mild regurgitation jet is present in 4 patients, and a marked jet, in 3. Postoperative cardiac catheterization performed in 5 patients has confirmed the Doppler echocardiographic findings. Although longer follow-up is necessary, this technique appears adequate for repairing a major prolapse of the anterior leaflet caused by multiple ruptured or elongated chordae, therefore obviating the need for a prosthetic valve substitute.