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Ann Thorac Surg 2006;82:826-827
© 2006 The Society of Thoracic Surgeons
Plymouth Hospitals NHS Trust, Department of Cardiac Surgery, Derriford Hospital, Plymouth, Devon PL6 8DH United Kingdom
(Email: malcolm.dalrymple-hay{at}phnt.swest.nhs.uk).
This is an interesting and important report [1] of a series of patients undergoing mitral valve surgery showing that mitral valve repair is of equivalent durability to mechanical mitral valve replacement. The authors have demonstrated that in their total experience the need for reoperation is significantly greater for patients who underwent repair for anterior mitral valve prolapse when compared with posterior or bi-leaflet prolapse. However more recently (1990–2000), as valve repair techniques have improved, the authors have demonstrated a significant reduction in the need for reoperation for patients who have isolated anterior mitral valve leaflet prolapse. This is now comparable with those patients who have posterior or bi-leaflet prolapse. This decrease in need for reoperation has not been associated with the survival benefit known to accompany repair of posterior or bi-leaflet prolapse.
The application of these findings to clinical practice merits further exploration. The timing of intervention in patients with severe degenerative mitral regurgitation remains ever changing. It is widely accepted that valve repair is the optimal surgical treatment in patients with severe nonrheumatic mitral regurgitation. When compared with valve replacement it carries lower perioperative mortality, and it provides improved survival and better preservation of postoperative left ventricular function than valve replacement. Recent series have highlighted the importance of operating on patients in New York Heart Association functional classes I and II compared with higher functional classes. Much of this data has been collected in patients with posterior mitral valve leaflet prolapse. Therefore the extrapolation of this data to patients with anterior mitral valve leaflet prolapse may not be valid; this is supported by the fact that although the durability of repair has improved, any survival benefit has not been documented in this series.
The reasons for this are probably multiple. The probability of a successful outcome is directly related to the ability to repair the valve. Until recently, anterior mitral valve leaflet prolapse has been more technically difficult to repair and the repairs are less durable with a subsequent higher need for reoperation. Referral has thus been later when the preoperative risk profile is less favorable. This is known to adversely affect survival. The demonstration of durable anterior leaflet repair techniques supports early referral, but the linearized increased risk of reoperation, while not significantly greater, is still threefold higher (0.5% per year posterior leaflet vs 1.64% per year anterior leaflet). The question remains unanswered as to whether further longer term follow-up of patients operated on in the more recent era with favorable preoperative risk profiles and a durable repair demonstrates improved survival.
Alternatively, prolapse of the anterior mitral valve leaflet may be a clinically distinct entity that needs to be separated from posterior or bi-leaflet mitral valve leaflet prolapse. The pathophysiology of anterior mitral leaflet prolapse and its impact on the left ventricle may be different to posterior or bi-leaflet prolapse, and early surgical correction is not be associated with an increased survival. This needs further evaluation; however it remains likely that decreasing left ventricular volume overload will improve long-term outcome.
The authors are to be congratulated on producing a large series with excellent clinical results. It supports early mitral valve intervention for all patients with mitral valve leaflet prolapse and in time may further the understanding of patients with mitral valve leaflet prolapse.
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