Aspekte der Mitralklappenrekonstruktion bei der chirurgischen Therapie der Mitralklappeninsuffizienz

Mitral valve repair (MVR) is the golden standard for the surgical treatment of mitral valve regurgitation and is superior to mitral valve replacement in terms of perioperative and long-term morbidity and mortality. However, the underlying disease has a significant impact on the functional long-term result of the repair. To evaluate the results of MVR, patients have to be divided by the underlying disease, degenerative mitral valve regurgitation, rheumatic mitral valve regurgitation, ischemic mitral valve regurgitation, and mitral valve regurgitation due to advanced cardiomyopathy. The best functional result for MVR can be achieved for degenerative mitral valve regurgitation (10-year freedom from reoperation for recurrent mitral regurgitation up to 94%) followed by patients with rheumatic mitral valve regurgitation (10-year freedom from reoperation for recurrent mitral regurgitation up to 82%). The progress in the underlying disease of the mitral valve is responsible for recurrent mitral valve regurgitation in these patients. For both underlying disease the 10-year survival rate is > 75%. For patients with ischemic mitral valve regurgitation the functional and survival rates are worse with a 5-year survival rate < 60% and recurrent mitral valve regurgitation > MI (mitral valve insufficiency) II degrees in 28% of patients within 6 months. However, ischemic mitral valve regurgitation is not a disease of the valve, it is a disease of the myocardium; thus, the myocardium is the key factor influencing the functional results of MVR and not pathologic changes in the mitral valve per se. There are no long-term results on patients operated on MI in conjunction with advanced cardiomyopathy; however, the initial mid-term results are encouraging with improved survival.Besides the underlying disease the timing of surgery is of utmost importance for the long-term survival; patients with preoperative NYHA functional class III/IV have a significantly worse short-term and long-term outcome compared to patients operated on for significant mitral valve regurgitation who have only minor or even no symptoms (NYHA class I/II). However, the compliance to undergo complex open-heart surgery via a median sternotomy in asymptomatic patients is very low. Minimally invasive endoscopic mitral valve repair may be an option to increase compliance in these patients, which will result in improved long-term survival with a normal life expectancy.