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Ann Thorac Surg 1999;68:820-824
© 1999 The Society of Thoracic Surgeons

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Original Articles: Cardiovascular

Is anterior leaflet repair always necessary in repair of bileaflet mitral valve prolapse?

^a Department of Thoracic and Cardiovascular Surgery, The Cleveland Clinic Foundation, Cleveland, Ohio, USA

Address reprint requests to Dr Gillinov, Department of Thoracic and Cardiovascular Surgery/F25, The Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH 44195
e-mail: gillinom{at}cesmtp.ccf.org

Presented at the Thirty-fifth Annual Meeting of The Society of Thoracic Surgeons, San Antonio, TX, Jan 25–27, 1999.

	Abstract

Top Abstract Introduction Patients and methods Results Comment Appendix References

 
Background. Traditionally, bileaflet prolapse has been treated by posterior leaflet resection combined with one of a number of procedures designed to support the anterior leaflet. However, most patients with bileaflet prolapse do not have important anterior chordal pathology. This study was undertaken to evaluate the effectiveness of a strategy of posterior leaflet resection and annuloplasty alone for patients with bileaflet prolapse and no anterior chordal rupture or severe anterior chordal elongation.

Methods. From 1993 to 1997, 93 patients with transesophageal echocardiography (TEE) demonstrated bileaflet prolapse and without anterior chordal rupture or important anterior chordal elongation had primary isolated mitral valve repair consisting only of posterior leaflet resection (quadrangular in 28 and sliding in 65) and annuloplasty (Cosgrove-Edwards in 83, pericardial in 9, and Carpentier-Edwards in 1). All patients had severe mitral regurgitation documented by intraoperative TEE. Mean age was 55 ± 13 years; 60% were men.

Results. Postrepair, mitral regurgitation was 0 to trace in 93% and 1+ in 7%. There were no operative deaths. Late follow-up was available in all patients, with 277 patient-years of follow-up available for analysis. Five-year actuarial survival was 95%. At a mean interval of 2.3 ± 1.3 (SD) years, echocardiography demonstrated no or trace mitral regurgitation in 65%, 1+ in 28%, and 2+ in 7%. No correlates of late mitral regurgitation were identified by multivariable analysis. No patient has required reoperation.

Conclusions. In the absence of significant anterior chordal pathology, a strategy of posterior leaflet resection and annuloplasty corrects anterior leaflet prolapse and mitral regurgitation, and provides a durable repair without the necessity of additional procedures on the anterior leaflet.

	Introduction

Top Abstract Introduction Patients and methods Results Comment Appendix References

 
Although mitral valve repair is possible in up to 95% of patients with mitral regurgitation of degenerative etiology [1], the presence of bileaflet prolapse traditionally complicates repair [2–4]. However, most patients with bileaflet prolapse do not have anterior chordal rupture or important anterior chordal elongation. In such patients, the anterior leaflet usually prolapses due to an inability to coapt with the posterior leaflet; this loss of support from the severely prolapsing or flail posterior mitral leaflet results in mild to moderate anterior leaflet prolapse. In this setting, correction of posterior leaflet prolapse alone should result in restoration of valve function. This study was undertaken to evaluate the effectiveness of a strategy of posterior leaflet resection and annuloplasty alone for patients with bileaflet prolapse and no significant anterior chordal pathology.

	Patients and methods

Top Abstract Introduction Patients and methods Results Comment Appendix References

 
Study group
From 1993 to January 1, 1997, 507 patients with mitral regurgitation caused by degenerative disease underwent isolated primary mitral valve repair at The Cleveland Clinic Foundation. These were identified as follows. Initially, the prospective Cardiovascular Information Registry (CVIR) was used to identify all patients having surgery for mitral regurgitation since 1993, the time at which intraoperative echocardiography became routine at our institution. The patients’ medical records and echocardiograms were then reviewed in detail, both to select those having degenerative disease and to verify the prospectively acquired CVIR clinical data. The study group was further refined by excluding patients having concomitant coronary artery, aortic valve, or arrhythmia (maze) operations.

Of these 507 patients, 133 had bileaflet prolapse documented by echocardiogram. Of these, 93 patients had no anterior chordal rupture or other important anterior chordal pathology identified by intraoperative echocardiography or surgical explortion. These 93 patients with bileaflet prolapse and no anterior chordal rupture constitute the study group.

Definitions
Degenerative valve disease was considered to be present when the patient had mitral regurgitation resulting from leaflet prolapse or annular dilatation and pathologic findings at operation were consistent with degenerative disease. The diagnosis of degenerative mitral valve disease was confirmed by echocardiographic and surgical findings. Leaflet prolapse was considered to be present if the free edge of the leaflet overrode the plane of the annulus during ventricular systole [1]. Patients with an enlarged, billowing anterior leaflet but no prolapse of the free edge were not included in this study.

Patient characteristics
Mean age at repair was 55 ± 13 years; 14 patients (15%) were 70 years of age or older. Fifty-six patients (60%) were men. All patients had severe mitral regurgitation. Ninety-eight percent of patients were in New York Heart Association functional class I or II. Comorbid conditions included atrial fibrillation in 34%, hypertension in 32%, diabetes in 9%, chronic obstructive pulmonary disease in 2%, and peripheral vascular disease in 1%.

Follow-up
Systematic CVIR follow-up every 2 years was supplemented by telephone interview in July 1998 with the patient or referring cardiologist, or both, for those not known to be dead and who had not been followed the previous year. One patient had been traced in mid-1996 after 1.3 years of follow-up, and 4 others had been followed in early 1997 after 0.8 to 3.8 years of follow-up. In toto, the patients had been followed 277 patient-years (range 0.8 to 5.5 years), with a mean follow-up of 3.0 ± 1.2 years and a median follow-up of 2.7 years. Late echocardiograms were available in 57 patients (61%).

Outcomes
Durability of mitral valve repair was assessed by review of late echocardiograms when available and by the event reoperation after valve repair. Other events investigated briefly were all-cause death, thromboembolism, bleeding, and endocarditis.

Data analysis
Nonparametric, non-risk-adjusted estimates of freedom from events were obtained by the methods of Kaplan and Meier [5]. Potential correlates of late mitral regurgitation were explored by multivariable analysis. Because the number of patients with late mitral regurgitation was so small, the multivariable analysis utilized logistic regression for the event mitral regurgitation grade 2+ or greater (more than mild mitral regurgitation). The potential risk factors (variables) entered into the analysis of late mitral regurgitation are listed in the Appendix.

	Results

Top Abstract Introduction Patients and methods Results Comment Appendix References

 
Surgical techniques and operative results
Figure 1 demonstrates the mechanism of bileaflet prolapse in patients with severe posterior leaflet prolapse and no anterior chordal rupture or important anterior chordal elongation. The anterior leaflet develops mild prolapse due to loss of posterior leaflet support at the zone of coaptation. Figure 2 depicts the typical findings on intraoperative transesophageal echocardiography (TEE) in a patient with bileaflet prolapse and no anterior chordal rupture. Prerepair, there is severe prolapse of the posterior mitral leaflet, resulting in mild anterior leaflet prolapse (Fig 2A). After posterior leaflet resection, sliding leaflet repair, and annuloplasty, there is no leaflet prolapse and no residual MR (Fig 2B). Intraoperative, prerepair echos demonstrated that the regurgitant jet was directed anteriorly in 60% of patients, centrally in 16% of patients, and posteriorly in 8% of patients. Sixteen percent of patients had multiple regurgitant jets. All patients had quadrangular resection of the prolapsing portion of the posterior mitral leaflet. In addition, 65 patients had a sliding repair of the posterior leaflet. All patients had an annuloplasty. Techniques used included Cosgrove-Edwards annuloplasty band (Baxter Healthcare Corp, Irvine, CA) in 83, posterior pericardial plication with Periguard graft (Baxter Healthcare) in 9, and Carpentier-Edwards annuloplasty ring (Baxter Healthcare) in 1. No other repair techniques were used.

View larger version (52K): [in this window] [in a new window]   Fig 1. Mechanism of bileaflet prolapse in patients with severe posterior leaflet prolapse and no anterior chordal rupture. (Top) Normal anatomy, with leaflet coaptation occurring at the annular level, denoted by the solid line. (Bottom) There is posterior leaflet flail due to chordal rupture. Anterior leaflet prolapse is caused by loss of posterior leaflet support at the zone of coaptation. (AL = anterior mitral leaflet;PL = posterior mitral leaflet; Ao = aorta.)

View larger version (63K): [in this window] [in a new window]   Fig 2. (A) Prerepair transesophageal echocardiogram of patient with posterior leaflet flail and mild anterior leaflet prolapse. The solid line indicates the plane of the annulus. (B) After posterior leaflet resection, sliding repair, and annuloplasty, bileaflet prolapse and mitral regurgitation are eliminated. (AL = anterior mitral leaflet; PL = posterior mitral leaflet.)

Follow-up
No patient has required reoperation for recurrent mitral valve dysfunction. At a mean interval of 2.3 ± 1.3 years after repair, late echocardiograms in 57 patients demonstrated no or trace mitral regurgitation in 65%, 1+ in 28%, and 2+ in 7%. No correlates of late mitral regurgitation were identified by multivariable analysis. Two patients have had thromboembolic events, and no patients have had endocarditis or anticoagulant-related hemorrhage. There were five late deaths, and three of these were of cardiac cause; 5-year actuarial survival was 95% (confidence interval 92% to 97%).

	Comment

Top Abstract Introduction Patients and methods Results Comment Appendix References

 
Mitral valve repair is the surgical treatment of choice for mitral regurgitation of all etiologies [1, 6, 7]. In patients with degenerative mitral valve disease, successful valvuloplasty is possible in 95% of cases [1]. Although degenerative disease affects all components of the mitral valve, it does not affect all parts of the valve with equal severity. The most common pathologic finding in degenerative disease is posterior leaflet prolapse caused by posterior chordal rupture or elongation; this is the sole cause of mitral regurgitation in 40% to 60% of patients in large surgical series [2, 8]. Such patients are treated by posterior leaflet resection and annuloplasty, and 10-year freedom from reoperation in this group is 97% [2].

Anterior leaflet prolapse and bileaflet prolapse are less common. However, up to one-third of patients with significant mitral regurgitation have anterior leaflet pathology [3, 8]. Treatment of anterior leaflet prolapse caused by anterior chordal pathology is a surgical challenge that results in increased surgical complexity [3, 4, 8]. Patients with significant anterior chordal pathology require application of specific repair techniques to the anterior leaflet and its chordae. Techniques used to treat anterior leaflet chordal pathology include chordal transfer, chordal shortening, artificial chordae, anterior leaflet resection, and free-edge leaflet plication [1, 3, 4, 8–15]. Each of these strategies has potential shortcomings, and there is considerable controversy concerning the durability of anterior leaflet repairs using the various repair techniques [2, 3, 14, 15].

The treatment of bileaflet prolapse is determined by the status of the chordae to the anterior leaflet. In the setting of advanced myxomatous changes of both leaflets with both anterior and posterior chordal pathology, the durability of valve repair is jeopardized [2, 4]. In such patients, valve replacement may be preferable to valve repair. However, most patients with echocardiographically demonstrated bileaflet prolapse do not have important anterior chordal pathology.

In this report, we describe our experience with a particular subset of patients with degenerative mitral valve disease—patients with bileaflet prolapse and no anterior chordal rupture or severe anterior chordal elongation. A review of our series of patients having mitral valve repair for degenerative disease revealed that 70% of patients with echocardiographically demonstrated bileaflet prolapse did not have important anterior chordal pathology. In this setting, mild to moderate anterior leaflet prolapse is caused by loss of support of the posterior leaflet at the zone of coaptation. The intact chordae of the anterior leaflet prevent severe anterior leaflet prolapse.

Because the anterior leaflet pathology was not pronounced in these patients, we employed a repair strategy consisting of posterior leaflet resection and annuloplasty alone. The majority of these patients had a relatively tall posterior leaflet, and a sliding leaflet repair was use to avoid postrepair SAM. However, adjunctive measures for the anterior leaflet such as chordal transfer, creation of artificial chordae, and free-edge plication were not employed. All patients had successful repair as assessed by intraoperative TEE, and at midterm follow-up, durability is excellent.

This study presents mid-term follow-up of patients having posterior leaflet resection and annuloplasty to treat echocardiographically identified bileaflet prolapse. Continued monitoring of these patients will be necessary to determine the long-term outcome of this strategy. In addition, echocardiographic follow-up is incomplete, with late echocardiograms available in 61% of patients. This study does not address the treatment of patients with bileaflet prolapse and anterior chordal rupture or severe anterior chordal elongation. Such patients require application of specific surgical techniques directed to the anterior leaflet and its chordae.

Most patients with bileaflet mitral valve prolapse caused by degenerative disease do not have significant anterior chordal pathology. In such patients, a strategy of posterior leaflet resection and annuloplasty corrects anterior leaflet prolapse and mitral regurgitation. Mid-term follow-up supports this strategy.

	Acknowledgments

 
We thank Judy Borsh, RN, Karen Mrazeck, and the other members of the thoracic and cardiovascular research team for their efforts in assembling and verifying the clinical data and performing the follow-up. Data management and preliminary statistical analyses were performed by Penny Houghtaling, MS, of the Department of Biostatistics and Epidemiology, Cleveland Clinic Foundation. We thank Luci Mitchin for her secretarial assistance.

	Appendix

Top Abstract Introduction Patients and methods Results Comment Appendix References

 
Variables included in multivariable analyses of risk factors for recurrent mitral regurgitation

Demography Age Gender Prerepair studies New York Heart Association functional class Chronic heart failure Emergency surgery Left ventricular function Grade of left ventricular dysfunction History of myocardial infarction Left ventricular hypertrophy Cardiac comorbidity Preoperative atrial fibrillation Number of coronary systems with >50% stenosis Family history of coronary artery disease Noncardiac comorbidity Diabetes Hypertension Cerebrovascular accident Peripheral vascular disease Chronic obstructive pulmonary disease Renal failure Blood urea nitrogen Repair Date of repair Type of annuloplasty Sliding leaflet repair

	References

Top Abstract Introduction Patients and methods Results Comment Appendix References

 

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): A. Marc Gillinov Delos M. Cosgrove, III Bruce W. Lytle Nicholas G. Smedira Patrick M. McCarthy Joseph F. Sabik Eugene H. Blackstone Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Gillinov, A. M. Articles by Blackstone, E. H. Search for Related Content PubMed PubMed Citation Articles by Gillinov, A. M. Articles by Blackstone, E. H.