Trends in mitral valve surgery: a single practice experience.

BACKGROUND AND AIM OF THE STUDY: Mitral repair has evolved to a point where three methods can be used to address most pathologies: full ring annuloplasty (RA) for annular disease; Gore-Tex artificial chordal replacement (ACR) for chordal disease; and autologous pericardial augmentation (PA) for leaflet disease. The study aim was to assess the impact of the increasing application of these methods on operative results over time. METHODS: Of 328 consecutive mitral valve procedures, 34% involved myxomatous prolapse, 23% rheumatic, 13% ischemic, 12% pure annular dilatation, 7% prosthetic dysfunction, 6% endocarditis, 3% hypertrophic obstructive cardiomyopathy (HOCM), and 2% 'other'. All patients underwent RA. Myxomatous prolapse was repaired with ACR, and ischemic and annular dilatation with RA alone. Rheumatic, endocarditis, and HOCM etiologies were repaired with all three methods. Patients were allocated to two-year increments, and also to repair versus replacement groups. Operative outcomes over time were assessed with linear and binomial regression. RESULTS: Overall, 66% of mitral valves were repaired; the average operative mortality was 6% (2% for repair, 7% for replacement), and 18% involved multiple valve procedures (mortality 16%). The extent of repair increased over time, from 55% to 100% of all etiologies. Over the same period, operative mortality fell from 6% in 1994 to 0% over the past six years. Other variables, such as age, presentation status, left ventricular dysfunction and etiology were relatively constant over the period. Reoperation rates after repair have been only 2% over the past 10 years of follow up. CONCLUSION: With recent innovations, most mitral disease can be repaired with combinations of RA, ACR and PA. Today, operative mortality is approaching zero, and one factor may be the increasing application of repair to all mitral pathologies. These data support the trend of expanding valve repair across most mitral disorders.

A new approach to mitral valve repair for rheumatic disease: preliminary study.

BACKGROUND AND AIM OF THE STUDY: The initial application of repair to rheumatic mitral disease was fraught with unacceptable recurrence rates. For this reason, rheumatic valves primarily have been replaced in recent years. Early and late outcomes with replacement, however, have continued to be suboptimal, prompting a re-examination of repair. METHODS: All eight patients encountered by the authors with rheumatic mitral valve disease over the past three years were considered for valve repair. One patient had pure stenosis, three patients had pure regurgitation, and four had advanced forms of mixed stenosis and regurgitation. Because posterior leaflet retraction was a prominent and almost uniform feature of rheumatic disease, posterior leaflet glutaraldehyde-fixed autologous pericardial gussets were placed in all cases. In the five patients with stenosis, commissural calcium was debrided, the thickened chords to the anterior leaflet were resected, extended commissurotomies performed, and an anterior leaflet 'hinge' mechanism restored. The anterior leaflet then was reattached to the base of the papillary muscles using Gore-Tex artificial chords, and all eight patients had full ring annuloplasties. RESULTS: Postoperatively, all patients had negligible gradients and no residual leak. The first patient (with mixed stenosis and regurgitation) was restudied with transesophageal echocardiography after three years, and had continued excellent valve function. There have been no intermediate-term recurrences, complications or mortalities. Operative videos and echocardiograms from these patients are available at JScottRankinMD.com. CONCLUSION: A combination of pericardial posterior leaflet gusset, anterior leaflet chordal resection/GoreTex replacement, extended commissurotomy and full ring annuloplasty allows the repair of rheumatic valves over a full range of pathologies. Early and intermediate-term results appear satisfactory. Continued aggressive application of this type of repair to rheumatic mitral disease seems to be indicated.