Neochordal repair of a double orifice mitral valve

Native double-orifice mitral valve is an exceedingly rare valvular abnormality. A 77-year-old patient was referred for a severe mitral regurgitation, and a double-orifice mitral valve with a central fibrous bridge was unexpectedly found. A flail anterior leaflet with 2 ruptured chordae was observed on the anterolateral mitral valve orifice, the leaflets on the posterior valve orifice were normally thin. Mitral valve repair was successfully performed with replacement of the 2 torn chordae by two 4/0 expanded polytetrafluoroethylene neochordae. We accordingly suggest that current mitral valve repair techniques remained a valuable option, even on central bridge double-orifice mitral valve regurgitation.     

Mitral valve repair of valve insuffficiency with broad and complex lesions due to infective endocarditis; report of a case

Surgical intervention is necessary for the treatment of infective endocarditis, although antibiotic therapy has been shown to be effective for treatment of this disorder. Mitral valve infective endocarditis frequently presents with broad and complex lesions, and thus a variety of valve repair is needed. A 40-year-old woman with mitral valve insufficiency due to infective endocarditis underwent mitral valve repair. During the operation, torn chordae, aneurysm with perforation of the anterior leaflet, and torn chordae of the posterior leaflet were found. The chordae of the anterior leaflet were reconstructed and the aneurysm was excised, and autopericardial patch repair was performed. Then, resection and suturing of the prolapsing lesion of posterior leaflet were performed. Mitral valve repair preserves the left ventricular apparatus and function. Therefore, mitral repair results in better prognosis than valve replacement. The repair of the mitral valve should be attempted for the treatment of valve insufficiency due to infective endocarditis.     

Artificial chordae

Expanded polytetrafluoroethylene sutures have been used for replacement of chordae tendineae since 1985. They have been used for correction of prolapse of mitral and tricuspid valve leaflets as well as for resuspension of the papillary muscles during mitral valve replacement when the native chordae cannot be preserved to maintain continuity between the mitral annulus and papillary muscles. The sutures used were 5CV Gore-Tex for replacement of the chordae tendineae of the anterior leaflet and 6CV for the posterior leaflet and commissural areas of the mitral valve. Initially one suture was used to create two artificial chordae, but as experience increased, the technique was modified and multiple pairs of artificial chordae were created with a single suture by passing successively through the fibrous portions of the a papillary muscle and the free margin of the prolapsing segment of leaflet, and tying the tends together on the papillary muscle head. This technique creates artificial chordae that are interdependent and their lengths are self-adjusting when pressure is exerted on the leaflets. From 1985 to 1998, 288 patients had artificial chordae used during mitral valve repair for degenerative disease of the mitral valve. Prolapse of both leaflets was present in 51% of patients, isolated prolapse of the anterior leaflet in 28%, and posterior leaflet in 21%. The mean follow-up was 4.8 +/- 3.0 years and was complete. At 10 years, the freedom from mitral regurgitation >2+ was 88 +/- 6% and the freedom from reoperation was 92 +/- 2%. Failures of repair were unrelated to the artificial chordae. Gore-Tex sutures are an excellent material to replace chordae tendineae, appear to be free of adverse effects, and have become a valuable adjunct to the surgical armamentarium to treat mitral and tricuspid valve disease.     

Mitral insufficiency due to ruptured chordae tendineae--clinical features, early and late results of valve replacement and repair

To evaluate the early and late results of mitral valve replacement and reconstruction for mitral insufficiency due to ruptured chordae tendineae respectively, 74 consecutive cases were analyzed. Fifty-five (74.3%) of the patients were men, and the mean age was 48 +/- 12 years old (range 16 to 76). The causes of the mitral disease were idiopathic in 50 (67.6%), rheumatic in 7 (9.4%) and infective endocarditis in 11 (14.9%) patients. In idiopathic 50 cases, 24 had mitral valve prolapse and 16 had both mitral valve prolapse and hypertension. Forty-one (55.4%) of the patients were in NYHA functional class III or IV preoperatively. Thirty (40.5%) cases underwent surgery within one year after their initial symptoms of heart failure onsets including six emergency operation cases due to uncontrollable acute lung edema. Chordae to anterior mitral leaflet were ruptured in 31 (a5, m16, p10)[41%] patients, to the posterior mitral leaflet in 45 (a4, m23, p18)[59%], and to both leaflets in one patient. Mitral valve replacement was performed in 68 patients (91.9%) and 6 patients (8.1%) underwent mitral valve repairs. Twenty cases underwent associated procedures that included tricuspid valve annuloplasty in 8, aortic valve replacement in 5 and myocardial revascularization in 4 cases. There were two operative deaths (2.4%); both occurred after replacement, left ventricular rupture in one and DIC in one. Mean follow-up period was 4.5 years (range 1 to 17) in 67 cases. There were four late deaths; all occurred after replacement. However five patients sustained mild mitral insufficiency after mitral valve repair including one that became worse of regurgitation three years after isolated Kay's annuloplasty, there were no cases that had needed reoperation and no late death after reconstruction. Left ventricular function and pulmonary arterial pressure were almost normalized in more than 90% cases postoperatively. Our data indicated that mitral valve reconstruction (McGoon's plus Kay's method as standardized maneuver) was the procedure of choice for selected patients with mitral insufficiency owing to ruptured chordae tendineae to the posterior mitral leaflet, including more limited patients with ruptured chordae to the anterior mitral leaflet.     

Surgical treatment for mitral regurgitation associated with secundum atrial septal defect]

We reviewed 25 patients who underwent a mitral valvuloplasty, from 1984 to 1996, for mitral regurgitation (MR) associated with atrial septal defect (ASD). Mean grade of MR was 2.3 +/- 0.7. The locations of mitral valve lesion were as follows; Postero-medial side of the anterior leaflet (AML) (11 patients: 44%), posteromedial side to center of the AML (7 patients: 28%), whole of the AML (5 patients: 20%), center of the AML (1 patient: 4%), posteromedial side of the posterior leaflet (PML) (1 patient: 4%). In summary, the mitral valve lesion was located in the AML in 96% patients and were seen in the postero-medial side of 96% patients. Mitral valve repair was performed as follows; chordae shortening only (3 patients: 12%), chordae shortening + Kay's annuloplasty (9 patients: 36%), Kay's anuloplasty (10 patients: 40%), using artificial chordae only (1 patient: 4%), using artificial chordae + Kay's annuloplasty (1 patient: 4%), using artificial chordae + ring annuloplasty (1 patient: 4%). In 24 patients, the grade of MR was less than 2/4 in the early postoperative period. In one patient, the grade of 3/4 MR was still remained. Reoperation were required in 2 patients, because of gradual increase of MR, 9 years and 10 years after the initial operation, respectively. In another patient, the grade 3/4 MR recurrently occurred at 6 months after the operation. He has been well maintained medically. In all 4 patients who had more than the grade 3/4 MR postoperatively, the annuloplasty was performed with Kay's method and the cause of MR was poor coaptation around the center of the AML. The mitral valve lesion associated with ASD seemed to be the dislocation of the AML which cause the discrepancy of the coaptation zone between both leaflets, without any prominent prolapse and chordae elongation. We put a particular emphasis on that the mitral valve repair should be performed with the recognition of the etiology of the mitral valve lesion. Especially, if the lesion extends around the center of the AML, sufficient coaptation area of both leaflets at the center of the AML should be obtained by anuloplasty.     

Mitral regurgitation due to ruptured chordae tendineae. Early and late results of valve repair

From 1958 through 1980, 131 patients had repair of ruptured chordae tendineae of the mitral valve; 62% were men. Ages ranged from 5 to 70 years (median 57). Chordae to the anterior mitral leaflet were ruptured in 44 patients (34%), to the posterior mitral leaflet in 85 (65%), and to both leaflets in two patients (1%). The mitral valve was repaired by leaflet plication without resection in 116 patients, plication after wedge resection of the unsupported leaflet in six, Ivalon sponge buttress of the posterior leaflet in three, resuspension of chordae in two, and annuloplasty alone in the remaining four. Mitral valve annuloplasty was performed in addition to leaflet repair in 115 patients (88%). Operative (less than 30 days) mortality was 6.1%. Survival rate of patients dismissed from the hospital was 92% at 5 years and 73% at 10 years. There were no differences in late survival or risk of reoperation for recurrent or residual mitral insufficiency between patients with ruptured chordae to the anterior leaflet and those with ruptured chordae to the posterior leaflet. Survival was significantly better for the group with repair than it was for a group that underwent mitral valve replacement for ruptured chordae during this same time interval (5 year survival rate, 92% versus 72%, p less than 0.003). The incidence of thromboembolism after repair was 1.8 episodes/100 patient-years compared with 8.0 episodes/100 patient-years after replacement. Our data indicate that valvuloplasty is the procedure of choice for most patients with mitral regurgitation owing to ruptured chordae tendineae, including selected patients with ruptured chordae to the anterior leaflet.     

Repair of flail leaflet of the tricuspid valve by a simple cusp remodeling technique

BACKGROUND AND AIM: The approach of repairing tricuspid valve insufficiency caused by congenital lack of chordae or traumatic rupture of chordae is often complicated and difficult. We try to present an alternative method and midterm results. METHODS: Between April 1997 and December 2004, eight patients (5 males, 3 females; mean age 23.9 +/- 5.8 years; range: 8 to 57 years) with severe tricuspid regurgitation (congenital lack of chordae in 5 cases and traumatic rupture of chordae in 3 cases) underwent surgical repair at Fu Wai Hospital. Four patients were in NYHA (New York Heart Association) class III, and 4 in class IV. Eight flail anterior leaflets and one flail septal leaflet of the tricuspid valve with massive tricuspid regurgitation were identified by echocardiography and the spaces of the free edges of the flail leaflets ranged from 20 to 30 mm. Tricuspid repair was performed under hypothermic cardiopulmonary bypass. The free edge of the affected cusp segment was sutured in folio, the segment of annulus devoid of leaflet was plicated, and the neo-annulus was fixed with a flexible annuloplasty ring. RESULTS: All patients survived and recovered after the operation. Echocardiography showed good coaptation with no regurgitation of the tricuspid valve in five patients and a mild residual tricuspid regurgitation in three patients. A remarkable decrease in the diameter of the right ventricle was observed, from a mean of 42.6 +/- 12.5 mm to a mean of 23.6 +/- 5.3mm (p < 0.01). Mean follow up was 50 +/- 42.9 months. Six patients were in NYHA class I, and two in class II and III. Except for one patient who had a mild-to-moderate increase in tricuspid regurgitation a year later, all the other patients were doing well. CONCLUSION: The procedure provided a simple and valuable option for repair of flail leaflet of tricuspid valve caused by congenital lack of chordae or traumatic rupture of chordae.     

Tricuspid valve repair for tricuspid valve endocarditis: tricuspid valve "recycling"

Tricuspid valve endocarditis traditionally has been treated with either valve excision or valve replacement. To avoid implantation of foreign material in an infected field, we have applied the principles of mitral valve repair to 4 patients with tricuspid valve endocarditis. On preoperative echocardiography, all patients had 3 to 4+ tricuspid regurgitation, evidence of progressive right ventricular enlargement, and mobile vegetations. In each case, up to three quarters of the anterior leaflet was excised en bloc with infected chordae and papillary muscle heads. Surgical procedures included standard quadrangular resection, conversion to a bicuspid valve, and pericardial patch replacement of the anterior leaflet with mobilization of basal chordae to replace resected marginal chordae. On postoperative echocardiography, tricuspid regurgitation and right ventricular dimensions were reduced in 2 of 4 patients in spite of loss of leaflet tissue. All excised valve tissue demonstrated bacteria on Gram stain or culture. Nonetheless, all repaired valves were successfully sterilized without recurrent infections. Tricuspid valve repair can allow eradication of infection with potential for improving valve competency in complicated tricuspid valve endocarditis.     

A surgical technique of tricuspid valve repair for infective endocarditis using an autologous pericardium

We report a surgically treated case of tricuspid valve endocarditis. A 33-year-old man was diagnosed with ventricular septal defect (VSD) and active infective endocarditis associated with severe tricuspid regurgitation. Ultrasonic echocardiography (UCG) showed vegetations attached to the tricuspid valve. His blood culture was positive for Streptococcus oralis. Although intravenous antibiotics therapy was effective, chest computed tomography( CT) revealed multiple septic pulmonary enboli in right lung and UCG showed severe tricuspid valve regurgitation. So we performed tricuspid valve repair by reconstructing septal leaflet using an autologous pericardium, expanded polytetrafluoroethylene( ePTFE) artificial chordae and annuloplasty ring. The postoperative course was uneventful, without tricuspid regurgitation or stenosis. He has been free from any complication for over 8 months. This surgical technique of tricuspid valve repair with an autologous pericardium and ePTFE artificial chordae for infective endocarditis might be useful choice of procedure for patients with leaflet destruction, in particular for young patients because of less recurrence of infection, less chance of anticoagulant therapy and expected long uneventful course.     

Mitral valve insufficiency: suspension of the posterior leaflet to the mitral annuloplasty ring

Mitral valve insufficiency in rheumatic heart disease is often due to retracted posterior chordae and posterior leaflet thickening. Several surgical repair techniques have been described, but sometimes an acceptable coaptation of the mitral leaflets can not be achieved. Rather than accept a mitral regurgitation or resort to a mitral valve replacement, particularly in children, we have added a suspension of the posterior leaflet directly to the annuloplasty ring. This additional surgical repair technique was performed in 10 patients with a perfect coaptation of the mitral leaflets with immediate results and excellent mid-term results, without evidence of either mitral regurgitation, mitral valve stenosis, or leaflet abrasion due to the suspension sutures.     

Surgical treatment for mitral regurgitation associated with secundum atrial septal defect

We reviewed 25 patients who underwent a mitral valvuloplasty, from 1984 to 1996, for mitral regurgitation (MR) associated with atrial septal defect (ASD). Mean grade of MR was 2.3 ±0.7. The locations of mitral valve lesion were as follows; Postero-medial side of the anterior leaflet (AML) (11 patients: 44%), posteromedial side to center of the AML (7 patients: 28%), whole of the AML (5 patients: 20%), center of the AML (1 patient: 4%), posteromedial side of the posterior leaflet (PML) (1 patient: 4%). In summary, the mitral valve lesion was located in the AML in 96% patients and were seen in the postero-medial side of 96% patients. Mitral valve repair was performed as follows; chordae shortening only (3 patients: 12%), chordae shortening + Kay’s annuloplasty (9 patients: 36%), Kay’s anuloplasty (10 patients: 40%), using artificial chordae only (1 patient: 4%), using artificial chordae + Kay’s annuloplasty (1 patient: 4%), using artificial chordae + ring annuloplasty (1 patient: 4%). In 24 patients, the grade of MR was less than 2/4 in the early postoperative period. In one patient, the grade of 3/4 MR was still remained. Reoperation were required in 2 patients, because of gradual increase of MR, 9 years and 10 years after the initial operation, respectively. In another patient, the grade 3/4 MR recurrently occurred at 6 months after the operation. He has been well maintained medically. In all 4 patients who had more than the grade 3/4 MR postoperatively, the annuloplasty was performed with Kay’ s method and the cause of MR was poor coaptation around the center of the AML. The mitral valve lesion associated with ASD seemed to be the dislocation of the AML which cause the discrepancy of the coaptation zone between both leaflets, without any prominent prolapse and chordae elongation. We put a particular emphasis on that the mitral valve repair should be performed with the recognition of the etiology of the mitral valve lesion. Especially, if the lesion extends around the center of the AML, sufficient coaptation area of both leaflets at the center of the AML should be obtained by anuloplasty.     

A case of ventricular septal defect with tricuspid regurgitation complicating infective endocarditis

A unique case of 52-year-old woman with a ventricular septal defect associated with tricuspid regurgitation complicating infective endocarditis was reported. Under cardiopulmonary bypass, the VSD was closed directly and tricuspid valve was replaced with a Carpentier-Edwards valve. Intraoperative examination showed that the VSD was perimembranous type (5 mm in diameter), all three leaflets were destroyed and one chordae of anterior leaflet was ruptured. Her postoperative course was uneventful and she has been well.     

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.     

Generation of chordae tendineae with polytetrafluoroethylene stents. Results of mitral valve chordal replacement in sheep

Surgical repair of ruptured or elongated chordae tendineae of the mitral valve is one of the most complex reconstructive techniques in cardiac surgery. Various surgical procedures have been described to repair chordal abnormalities of the anterior leaflet of the mitral valve with unpredictable results. Mitral valve replacement is usually recommended in that situation. This report describes a simple repair technique that we have devised. We resected one or two marginal chordae of the anterior leaflet of the mitral valve in 35 sheep and replaced them with a double-armed, pledget-supported, expanded polytetrafluoroethylene suture. The 30 surviving animals were studied hemodynamically and were electively put to death 3, 6, 9, 18, and 24 months after the operation. Mitral insufficiency did not develop in any of the sheep. All specimens had a normal mitral valve without thrombosis. The polytetrafluoroethylene suture remained pliable and was incorporated into the anterior leaflet and papillary muscle. Scanning and transmission electron microscopy showed that the suture was completely covered by a sheath of tissue with a collagen structure remarkably similar to that of a native chorda. Calcification was not detected in the new chordae. This reproducible and safe technique may considerably simplify the difficult repair of chordal abnormalities.     

Partial replacement of the tricuspid valve by mitral homografts in acute endocarditis

Background. Seven patients with acute tricuspid endocarditis underwent partial replacement of the tricuspid valve using mitral homograft tissue. Valve function was evaluated at midterm.

Methods. Operative indications were uncontrolled sepsis in all cases associated with heart failure symptoms in 3 patients and septic pulmonary emboli in 2 patients. These patients were referred to our institution after a course of antibiotic treatment ranging from 7 to 12 weeks. Lesions found at the level of the anterior leaflet of the tricuspid valve were vegetations and rupture of more than half of the marginal cords in all patients. Vegetations were also found on the posterior leaflet in 5 patients. In all instances the septal leaflet was free of lesions. The aortic valve was involved in 4 patients and the pulmonary valve in 1 patient. All patients underwent resection of the anterior and posterior leaflets of the tricuspid valve with their corresponding papillary muscles leaving the septal leaflet in place. Replacement of the tricuspid valve was performed through a right longitudinal atrial access, using the anterior leaflet of a mitral homograft alone in 3 patients and the anterior leaflet with part of posterior leaflet in 4 patients. Associated procedures included aortic valve replacement by a homograft (n = 4) and pulmonary valve reconstruction (n = 1).

Results. No hospital deaths are reported. One late death, at 16 months, is reported after reoperation due to recurrent aortic valve endocarditis. At midterm (mean follow-up, 30 months) patients had excellent functional status and normal valvular function during echocardiographic studies.

Conclusions. We conclude that when the degree of tricuspid valve destruction prevents repair, partial homograft replacement can be used as an extension of the already existing reconstructive techniques, with excellent functional results.     

Partial tricuspid valve transfer for repair of mitral insufficiency due to ruptured chordae tendineae

BACKGROUND: A new technique is suggested for the reconstructive surgical treatment of mitral regurgitation. It involves partial transfer of the tricuspid valve of the patient to the mitral valve, in order to provide chordae to correct anterior leaflet prolapse of the mitral valve, secondary to rupture of the chordae tendineae. METHODS: From January 1991 to May 1997, 20 patients with mitral insufficiency due to rupture of the chordae were operated on. The prevailing cause was myxomatous degeneration (70%). Patients were in New York Heart Association functional class III and IV. RESULTS: There were no hospital deaths. Two patients were reoperated on. Eighteen patients (90%) are alive with their own valves (class I and II). Doppler echocardiogram mean values were: ejection fraction, 0.65; left atrial diameter, 4.2 cm; mitral area, 2.4 cm2; mitral transvalvular gradient, 3.3 mm Hg. No regurgitation or mild regurgitation was observed in 16 (94.1%) of the 17 cases evaluated. Mean tricuspid valvular area was 3.3 cm2. In all cases, no tricuspid regurgitation was present or it was mild. CONCLUSIONS: Partial transfer of the tricuspid valve to the mitral valve is an effective procedure for the surgical treatment of mitral valve insufficiency secondary to ruptured chordae tendineae of the anterior leaflet.     

Early and late results of partial plication annuloplasty for congenital mitral insufficiency

BACKGROUND: Partial plication annuloplasty is the main technique for congenital mitral insufficiency because this technique allows the mitral anulus to grow, in contrast to ring annuloplasty. However, this technique is not satisfactory for mitral insufficiency with some anomalies of the mitral valve apparatus. METHODS: Forty-one patients underwent partial plication annuloplasty for mitral regurgitation from July 1979 to December 1998. Mitral regurgitation associated with an atrioventricular defect, an atrioventricular discordance, and a univentricular heart was excluded from this study. RESULTS: There were no early or late deaths. In early results, partial plication annuloplasty was more effective for mitral regurgitation with abnormality of the posterior leaflet (n = 14) or normal leaflet motion (n = 8) than with abnormality of the anterior leaflet and its apparatus (n = 14) or absence of chordae (n = 4). The mean follow-up period was 145.8 months. During the follow-up period, 2 patients underwent mitral valve replacement, and a third patient underwent mitral valve repair with partial plication annuloplasty after the first repair. The main cause of mitral regurgitation of 2 of the 3 patients was absence of chordae. The actuarial freedom from reoperation rate was 94.9% +/- 3.6%, 91.9% +/- 4.7%, and 91.9% +/- 4.7% at 5, 10, and 15 years after the operation, respectively. CONCLUSION: Early and long-term results of partial plication annuloplasty were acceptable for congenital mitral insufficiency with any type of malformation of the mitral valve, and results were excellent with abnormality of the posterior leaflet and its apparatus or normal leaflet motion. However, late results were suboptimal for mitral regurgitation with absence of chordae. Other techniques, such as artificial chorda replacement, should be adapted in these cases.     

Mitral valve repair with artificial chordal creation

To achieve optimal long-term result of mitral valve repair, artificial chordae creation has got to be an important technique. Artificial chordae creation can preserve leaflet motion of the posterior mitral leaflet and soft coaptation area. Loop technique is suitable technique for creation of multiple artificial chordae, especially in minimally invasive minithoracotomy setting. Loop-in-loop technique is a new technique to realize easy adjusting of the length of the neochordae using slippery Gore-Tex suture. Loop-in-loop technique helps surgeons to afford variety of mitral valve repair techniques and manage complex mitral valve pathologies.     

The long-term results of commissure plication annuloplasty for congenital mitral insufficiency.

BACKGROUND: Mitral valve repair in the pediatric population remains demanding because of a diversity of apparatus anomalies and the young age of the patients. METHODS: We reviewed our clinical results for mitral valve repairs for congenital mitral insufficiency. Forty-nine consecutive patients aged 2 months to 34 years (mean, 4.4 years) had mitral valve repair between June 1984 and December 1996. Forty-one patients (83.7%) had associated cardiac anomalies. The predominant pathologies for the regurgitations were chordal anomalies in 34 patients (69%), annular dilatation in 8 (16%), and leaflet anomalies in 7 (14%). Mitral valve repair included commissure plication annuloplasty in 43 patients (88%), modified DeVega in 11, cleft closure in 5, plication of the anterior leaflet in 3, triangular resection of the anterior leaflet in 2, chordal shortening in 1, and placement of artificial chordae in 1. Several combined techniques were required in 19 patients. RESULTS: There were no early or late deaths. The follow-up period was from 6 to 166 months (mean, 88.4 months). Forty-seven patients (95.9%) were in New York Heart Association class I. The long-term echocardiographic studies showed that 2 of 30 patients without reoperation had moderate regurgitation. The actuarial freedom from reoperation was 85.6% (95% confidence limits, 72.8%, 98.4%) at 13 years. Five patients (10.2%) required valve replacement from 13 days to 75 months after the valve repair. Two patients had cerebral ischemic events as a result of cardiomegaly and atrial fibrillation. CONCLUSIONS: Valve repair for congenital mitral insufficiency gave adequate results in combination with commissure plication annuloplasty and other techniques with excellent long-term functional status.     

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.