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Ann Thorac Surg 1997;64:445-450
© 1997 The Society of Thoracic Surgeons

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Original Articles: Cardiovascular

Valve Repair for Mitral Regurgitation Caused by Isolated Prolapse of the Posterior Leaflet

Herz und Gefäß Klinik, Bad Neustadt/Saale, Germany

Accepted for publication February 24, 1997.

	Abstract

Top Footnotes Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
Background. Although prolapse of the posterior leaflet is the most common abnormality of the mitral valve causing dysfunction, the long-term results of mitral valve repair for this condition are seldom reported.

Methods. From October 1988 to June 1994, 208 patients (mean age, 59.4 years) with mitral regurgitation caused by isolated prolapse of the posterior leaflet underwent mitral valve repair alone or combined with myocardial revascularization (n = 30). The surgical techniques were quadrangular resection (n = 199) followed by annulus plication (n = 101) or sliding leaflet plasty (n = 98), use of artificial chordae (n = 5), or papillary muscle shortening (n = 4). All patients had an annuloplasty with a Carpentier ring. Mean follow-up was 3.4 ± 0.1 years and total follow-up, 656 patient-years.

Results. There were six operative deaths (2.9%). Postoperative Doppler echocardiography found two cases of systolic anterior motion (1%), and echocardiographic studies at follow-up showed satisfactory mitral valve function in 97% of 112 patients. At 6 years, the actuarial survival rate was 87% ± 7%, and freedom from thromboembolic complications, bleeding complications, and reoperation was 93% ± 7%, 95% ± 3%, and 95% ± 4%, respectively.

Conclusions. Mitral valve repair for regurgitation caused by prolapse of the posterior leaflet provides excellent survival at 6 years and should be considered the method of choice for its surgical treatment.

	Introduction

Top Footnotes Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
Prolapse of the posterior leaflet as a result of ruptured chordae was the first abnormality of the regurgitant mitral valve to undergo surgical correction [1]. The term prolapse is broadly used and applied schematically to two different situations. Very often it describes a normally functioning mitral valve with no regurgitation but with a morphologic particularity: the billowing of mitral leaflet bodies toward the left atrium. Conversely, the term prolapse is also used, as in this study, to describe a specific abnormality of a regurgitant mitral valve. The definition of this abnormality is one shared by surgeons [2] and some cardiologists [3]: prolapse of the posterior leaflet of the mitral valve is a failure of leaflet coaptation resulting in displacement of a part of the free edge of the posterior leaflet toward the left atrium.

Several surgical techniques have been described to repair prolapse of the posterior leaflet: plication of the flail leaflet segment [1], quadrangular resection followed by either annulus plication [4] or sliding leaflet plasty [5], or artificial chordae implantation [6, 7]. Most often, these techniques are associated with an annuloplasty. The appropriate application of these different techniques is subject to differences of opinion. Although prolapse of the posterior leaflet is the most frequent cause of mitral insufficiency and is easily amenable to repair, follow-up data are few. Here we report our experience with valve repair of isolated prolapse of the posterior leaflet of the mitral valve, present the different surgical techniques performed, and discuss their use.

	Patients and Methods

Top Footnotes Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
From October 1988 to June 1994, 522 patients with mitral insufficiency underwent mitral valve repair in our institution. Of this group, 208 (40%) had isolated prolapse of the posterior leaflet, and they form the study cohort. The patients ranged in age from 27 to 79 years (mean age, 59.4 ± 10.5 years). The preoperative clinical profile of these patients is shown in Table 1. Thirty patients had concomitant coronary artery disease, and 12 of them had sustained a myocardial infarction. The preoperative Doppler echocardiographic data obtained in 103 unselected patients are shown in Table 2.

Seven patients had extensive calcification of the posterior portion of the annulus. Mitral valve repair was carried out after decalcification and reconstruction of the annulus as previously described [8].

In all patients, a Carpentier-Edwards annuloplasty ring (model 4400; Baxter Healthcare Corporation, Santa Ana, CA) was used to reduce the size of the annulus, reshape it, and reinforce the repair. The ring sizes used are reported in Table 3.

Thirty patients had concomitant myocardial revascularization (2.12 grafts per patient). Two patients experienced acute ischemic mitral regurgitation requiring urgent operation within 2 weeks after a myocardial infarction. Fourteen patients had associated tricuspid valve repair using a Carpentier-Edwards annuloplasty ring. Other associated procedures included closure of an atrial septal defect (7 patients), carotid endarterectomy (4 patients), left ventricular aneurysmectomy (1 patient), and septal myectomy (1 patient).

Intraoperative Doppler echocardiography was not used routinely. However, all patients were studied before discharge from the hospital.

Anticoagulation
All patients received oral anticoagulants starting 3 days postoperatively (phenprocoumon). The efficacy of anticoagulation was assessed by the international normalized ratio, which was maintained between 3.0 and 4.5. After 3 months, anticoagulant treatment was discontinued at the discretion of the referring physician provided the patient was in sinus rhythm. At the time of the study, 67 patients were anticoagulated, and 32 were receiving antiplatelet therapy.

Follow-up
Information on hospital mortality and complications was collected as part of the follow-up. Long-term follow-up was completed between January and September 1996 through questionnaires and telephone contacts with patients and the referring physicians. The average duration of follow-up was 3.4 ± 0.1 years. The cumulative follow-up was 656 patient-years. One patient (0.5%) was lost to follow-up.

Statistical Analysis
Computerized statistical analysis of the data was accomplished using the Sedistat software package (Sedia SA, Paris, France). Standard actuarial and linearized statistical techniques were used to describe survival and incidence of valve-related complications. Student's t test and ² contingency tables were used to analyze the significance of differences between preoperative and postoperative data. Continuous data are presented as the mean ± the standard deviation and actuarial probability estimates and linearized rates, as the mean ± two standard errors of the mean.

Results were reported according to the recommendations of the Ad Hoc Liaison Committee for Standardizing Definitions of Prosthetic Heart Valve Morbidity [9].

	Results

Top Footnotes Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
Operative Results
Six patients died in the hospital, for an operative mortality rate of 2.9%. Of these patients, 5 had had concomitant coronary artery bypass grafting, 2 on an urgent basis within 2 weeks after a myocardial infarction, and 1 had had tricuspid valve repair. The early deaths were due to secondary bleeding complications with tamponade (3 patients), low cardiac output (2 patients), and colon perforation (1 patient). There were no early deaths in the 157 patients with isolated mitral insufficiency.

The postoperative complications were as follows: reexploration for bleeding, 8 patients (3.8%); need for a permanent transvenous pacemaker, 7 (3.4%); low cardiac output, 6 (2.9%); ischemic cerebral infarction, 3 (1.4%); transient cerebral ischemic attack, 3 (1.4%); and systolic anterior motion of the mitral leaflet, 2 (1.0%). The mean length of stay in the intensive care unit was 2.1 ± 4.4 days. The patients were discharged from the hospital after 9.2 ± 4.3 days.

An echocardiographic evaluation of the repaired mitral valve was performed in 195 patients before discharge. Data on left atrial diameter, left ventricular dimensions, mean gradient across the valve, mitral valve area, and left ventricular shortening fraction are presented in Table 4 together with the evaluation of postoperative mitral regurgitation. Preoperative echocardiographic data obtained in 103 patients were compared with the postoperative data from the same 103 patients (see Table 2). Six to 8 days after mitral valve repair, the left atrial and the left ventricular end-diastolic diameters were significantly reduced.

Survival
There have been 13 late deaths. The actuarial survival rates at 1 year and 6 years were 97% ± 2% and 87% ± 7% respectively. Figure 1 shows the actuarial survival curve, including early mortality. The causes of late death were sudden death (2 patients), congestive heart failure (3 patients), and noncardiac (8 patients).

View larger version (17K): [in this window] [in a new window]   Fig 1. . Actuarial survival.

View larger version (18K): [in this window] [in a new window]   Fig 2. . Actuarial freedom from thromboembolic complications.

View larger version (17K): [in this window] [in a new window]   Fig 3. . Actuarial freedom from bleeding complications.

View larger version (16K): [in this window] [in a new window]   Fig 4. . Actuarial freedom from reoperation.

View larger version (18K): [in this window] [in a new window]   Fig 5. . Actuarial event-free survival.

Postoperative Functional Class
At the time of follow-up, 130 patients (70%) were in New York Heart Association functional class I, 51 (27%) were in class II, 5 (3%) were in class III, and 1 patient (0.5%) was in class IV. We were unable to obtain the postoperative functional class for 1 patient. One hundred seventy-six patients (94%) subjectively thought their condition was improved, 6 (3%) thought it unchanged, and 5 (3%) claimed their condition was worse.

	Comment

Top Footnotes Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
Since 1960 when McGoon [1] reported the first mitral valve reconstruction, extensive experience with mitral valve repair has been documented [10–12]. These studies present results for nonhomogeneous cohorts of patients with mitral insufficiency resulting from different causes and of different functional types requiring an extremely wide range of surgical techniques. David [12], Cohn [13], and their co-workers reviewed their experience with patients with mitral insufficiency caused only by degenerative disease, but a certain proportion of patients showed preponderant or associated prolapse of the anterior leaflet. The patients in our study exhibited prolapse of only the posterior leaflet, which can be easily repaired using straightforward techniques.

Degenerative disease of the mitral valve has been recognized as the most frequent cause of mitral insufficiency in industrialized countries [14]. Analysis of mitral valves with regurgitation resulting from degenerative disease shows that in the majority of cases, the dysfunction is a result of prolapse of the posterior leaflet because of either elongated or ruptured chordae [15]. There is currently little controversy that this lesion should be repaired, as comparative studies [16, 17] demonstrate better long-term survival after valve repair than after valve replacement.

It is interesting to note that 9 patients with an ischemic mitral insufficiency had prolapse of the posterior leaflet because of a true ischemic lesion of one head of the posterior papillary muscle supporting chordae of the posterior leaflet exclusively (fibrotic elongation in 5 patients and necrotic rupture in 4). Two of these patients died postoperatively; because of an unstable hemodynamic situation, both had operation on an urgent basis within 2 weeks after a myocardial infarction.

Our survival data strongly support the necessity of reconstructing the mitral valve when there is prolapse of the posterior leaflet. The 87% survival rate at 6 years for the entire group of 208 patients is similar to the rates in other reports [10–12].

The actuarial rate of freedom from reoperation of 95% at 6 years compares favorably with results in the literature. Nevertheless, in 3 of our patients, an unsatisfactory repair that led to a reoperation could have been recognized at the time of the first operation if intraoperative transesophageal echocardiography had been routinely performed. This emphasizes the role of intraoperative transesophageal echocardiography to increase the predictability and the stability of mitral valve repair.

Most of the thromboembolic complications occurred during the early postoperative period when the patient was not yet anticoagulated. Early anticoagulation with heparin sodium has also been advocated [10] and could be a way to reduce these complications. Nevertheless, we stress that this study is retrospective, the patients and their referring physicians being ask to remember events that occurred several years earlier. The data presented are reasonably accurate for the most dramatic events—death, reoperation, and major bleeding and thromboembolic complications. Minor events such as some thromboembolic or bleeding complications are probably underestimated.

Three groups of pathologic features were identified when the mitral valve was examined either at operation or during preoperative echocardiography. These were directly related to the cause and had a direct influence on the choice of surgical technique used. The various techniques at our disposal should not be considered as competitive but rather as alternative possibilities. A very large prolapsed area, which would be impossible to resect as a whole, can be treated by a partial quadrangular resection associated with artificial chordae. A prolapse with localized excess tissue can be corrected with a quadrangular resection followed by a partial sliding-leaflet plasty associated with plication of the annulus. It is even possible to combine all of these techniques in a single patient, for instance, quadrangular resection and use of artificial chordae, sliding leaflet plasty, and partial plication of the annulus, if the anatomic and pathologic findings warrant their application.

Schematically, the following approach was used to determine which surgical technique to apply:

Whenever a floppy or billowing valve was identified, a sliding leaflet plasty was performed [5]. These mitral valves were characterized by an excessive amount of myxomatous tissue in a portion of the posterior mitral leaflet where the distance from its distal margin to its attachment at the mitral annulus was clearly elongated, thus altering the usual 2:1 ratio of the anterior to posterior leaflet surface area. A severe annular dilatation was usually present. As reported by Mihaileanu and associates [18], an excess of valvular tissue is associated with a higher risk of left ventricular outflow tract obstruction. To minimize this risk, the patients with obvious signs of floppy valves had a sliding leaflet plasty to remove this excess tissue, restore a normal ratio of anterior to posterior leaflet surface area, and achieve a regular and progressive narrowing of the mitral annulus, thus avoiding any major change in the geometry of the posterior wall of the left ventricle. The validity of this approach has been presented previously [19]. In our series, this condition was encountered in 98 patients (49%).

When the amount of leaflet tissue was not excessive and an associated dilatation of the annulus existed, the repair was achieved by quadrangular resection followed by plication of the annulus and implantation of a ring. This situation corresponds to the fibroelastic deficiency described by Carpentier and colleagues [2]: the leaflets were thin, smooth, and without excess tissue. The annulus was moderately dilated. One hundred one patients (51%) were in this group.

When no associated annular dilatation and no excess tissue were detected, a quadrangular resection was avoided, as it would dramatically change the geometry of the posterior leaflet and reduce its functional area. In these patients, the prolapse was corrected by implantation of artificial chordae (5 patients) or shortening of a papillary muscle (4 patients). Whether an annuloplasty ring should be implanted in this group is open to debate.

This surgical approach provided good, stable results with only a 1% incidence of systolic anterior motion, which is lower than that in the literature [12, 18, 20].

In summary, the results of mitral valve repair in patients with isolated prolapse of the posterior leaflet demonstrate low morbidity and mortality, especially when surgical techniques are adapted to the anatomy and the pathology of the mitral apparatus. Mitral valve repair should be considered the method of choice to surgically treat this most common form of mitral insufficiency in industrialized countries.

	Acknowledgments

Top Footnotes Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
We express our gratitude to Daniela Bäuml and Sylvia Kippnich for their help in the follow-up of patients.

	Footnotes

Top Footnotes Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
Address reprint requests to Dr Perier, Institut Arnault Tzanck, Avenue Maurice Donat, 06721 Saint Laurent du Var, France.

	References

Top Footnotes Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 

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This Article Abstract 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): Patrick Perier André Schneider Robert Hacker Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Perier, P. Articles by Hacker, R. Search for Related Content PubMed PubMed Citation Articles by Perier, P. Articles by Hacker, R.