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Ann Thorac Surg 2006;81:2339
© 2006 The Society of Thoracic Surgeons
Harefield Hospital, Hill and Road Harefield, Middlesex, UB9 6JH, United Kingdom
(Email: g.dreyfus{at}rbh.nthames.nhs.uk).
We have read with great interest the article by Gillinov and colleagues [1], which raises many questions. Alain Carpentier [2] primarily pioneered the discipline of mitral valve repair. Long-term, good outcome has focused on three inviolate principles: (1) restoring leaflet motion without restriction, (2) creating a good surface area of leaflet coaptation, and (3) reshaping the mitral orifice.
Recent trends seem to bypass these basic principles in order to avoid the learning curve, which leads to expertise in mitral valve repair techniques. Such new philosophies as promoted in the Alfieri stitch [3] have progressively moved from a single stitch in between A2 and P2 to a complete suturing of A2 to P2 in Barlow's disease. In the same thread Gillinov and colleagues [1] start from Carpentier's magic stitch and now advocate complete suturing of the commissural area in case of commissural prolapse. They mention 15% to 20% reduction in circumference, which reduces the surface area by 30% to 40% if one closes the complete prolapsed area as they suggest. It is quite unlikely that leaflet suturing would reduce circumference rather than surface alone. This may treat commissural prolapse, but undoubtedly it should impair mitral leaflet motion.
Commissural prolapse is commonly believed to be a difficult lesion to treat. We believe that it is one lesion among many others that affects the degenerative mitral valve. It most often involves the posterior commissure. At this level the posterior papillary muscle has 3 heads: (1) one anterior for the anterior leaflet, (2) one intermediate for the commissural area, and (3) one posterior for the posterior leaflet. We have described a very efficient technique to treat anterior leaflet prolapse that applies very easily to commissural prolapse named papillary muscle repositioning [4]. By dividing the anterior and posterior head from the intermediate one, it becomes easy to bring further down into the ventricle all chordae arising from this head and subsequently treating commissural prolapse without tissue resection or tissue restriction by direct suturing. Similarly the same can be applied to the anterior commissure.
The Gillinov and colleagues' [1] technique seems physiologically questionable as it may favor dynamic mitral stenosis, but it also raises questions of long-term durability of such maneuvers by creating abnormal stress at the suturing level (without adequate chordal support). Any new surgical techniques should be welcome; however some principles should not be forgotten. The excellent long-term results of Carpentier's techniques, which have made mitral repair the gold standard for surgical treatment of mitral regurgitation despite some modifications such as polytetrafluoroethylene chordae or papillary muscle repositioning, have gained their success by still honoring the original principles: (1) maintain as much leaflet motion as possible, (2) create a good surface area of leaflet coaptation, and (3) reshape annuloplasty without restriction in any way.
Such principles have provided 30 years of durability [5]. It is to be wondered if some new approaches that bypass these principles will just make short-term results much easier to achieve, but long-term results much less reliable.
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  A. M. Gillinov and D. M. Cosgrove III Reply Ann. Thorac. Surg., June 1, 2006; 81(6): 2339 - 2340. [Full Text] [PDF]
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