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Original Articles: Adult Cardiac

Toward a New Paradigm for the Reconstruction of Posterior Leaflet Prolapse: Midterm Results of the "Respect Rather Than Resect" Approach

Herz und Gefäss Klinik, Bad Neustadt/Saale, Germany

Accepted for publication May 6, 2008.

^_* Address correspondence to Dr Perier, Herz und Gefäss Klinik, Salzburger Leite 1, Bad Neustadt/Saale, 97616, Germany (Email: pperier{at}club-internet.fr).

Presented at the Forty-fourth Annual Meeting of The Society of Thoracic Surgeons, Fort Lauderdale, FL, Jan 28–30, 2008.

Dr Perier discloses that he has a financial relationship with Edwards Lifesciences.

 

	Abstract

Top Abstract Introduction Patients and Methods Results Comment Discussion Acknowledgments References

 
Background: The aim of mitral valve reconstruction is restoration of good coaptation surface. Resection of the prolapsed area has been the accepted technique to repair prolapse of the posterior leaflet (PPL). However, as leaflet tissue is the basic component of coaptation surface, the logical corrective approach was thought to be the transformation of the posterior leaflet into a smooth vertical buttress without resection, the "respect rather than resect" approach.

Methods: Between 1994 and 2004, 225 patients underwent a PPL repair for severe mitral regurgitation with the respect rather than resect approach, in which the prolapse was corrected with artificial chordae. In 193 patients, the prolapse was limited to the posterior leaflet; in the remaining 32 patients, both leaflets were involved. All patients received ring annuloplasty. Associated procedures included myocardial revascularization (21 patients) and tricuspid repair (19 patients). Patient demographics were as follows: mean age, 60.7 ± 12.9 years; male, 150 (67%); asymptomatic, 102 (45%).

Results: Three patients died postoperatively (1.3%). Survival at 10 years (88% ± 6%) was similar to expected survival rate (97% ± 2% for asymptomatic patients and 82% ± 10% for symptomatic patients (p < 0.005)). Ten patients were reoperated on, for a freedom from reoperation rate of 93% ± 3% at 10 years. At echocardiographic follow-up, 172 patients of 195 (88%) showed mitral regurgitation of 1 or less; and 195 of 203 patients (96%) were in New York Heart Association functional class I or II.

Conclusions: The respect rather than resect approach is safe, effective, and durable, and increases technical repair possibilities. Surgical strategy focuses on restoration of surface coaptation instead of location and extent of leaflet resection.

This article has been selected for the open discussion forum on the CTSNet Web Site: http://www.ctsnet.org/sections/newsandviews/discussions/index.html

 

Prolapse of the posterior leaflet (PPL) is the most frequent dysfunction of the degenerative mitral valve; it was the first lesion accessible for repair [1]. Alain Carpentier developed and conceptualized the functional approach for mitral valve reconstruction aiming at the restoration of the coaptation surface, the essence of the "French correction" [2]. Leaflet resection followed by either annulus plication [3] or sliding leaflet plasty [4] has been the gold standard technique to repair PPL and has demonstrated excellent long-term results [5, 6]. However, a surgeon may face myriad questions during the course of a so-called "straightforward quadrangular resection" such as these: How large should the resection be? What if the prolapse involves a very large P2, leaving two tiny leaflet remnants, after its resection? What if the prolapse involves an additional scallop? Should an annulus plication with its subsequent deformation of the subannular area and the theoretical risk of kinking the circumflex artery be performed to close the gap after resection? Should a sliding plasty be undertaken to have a more regular distribution of stresses and minimize the risks of systolic anterior motion in case of excess tissue?

An alternative for the correction of PPL without leaflet resection has been proposed [7]. The goal of the "respect rather than resect" (RRR) approach is to correct the prolapse without leaflet resection and to transform the posterior leaflet into a smooth and vertical buttress ensuring the best coaptation surface. This study details our experience with the RRR approach to the repair of PPL.

	Patients and Methods

Top Abstract Introduction Patients and Methods Results Comment Discussion Acknowledgments References

 
From 1994 to 2004, 1048 patients with mitral regurgitation (MR) due to PPL underwent mitral valve repair in our institution. Of this group, 225 patients (21.5%) had their mitral valve repaired with the RRR approach, and form the cohort of this study. Patients were included based on the surgeon's decision after surgical valve analysis. At the beginning of the study, patients were cautiously enrolled until confidence in the technique was increased. Preoperatively, 102 patients were in New York Heart Association (NHYA) functional class I or II (asymptomatic group), and 123 were in NYHA III or IV (symptomatic group). In age, patients ranged from 19 to 84 years (mean, 60.7 ± 12.9). Mean age was 56.2 ± 12.5 years for the asymptomatic group and 64.4 ± 12.2 years for the symptomatic group (p < 0.01). The preoperative clinical profile of these patients is presented in Table 1. Preoperative Doppler echocardiographic variables are shown in Table 2.

Operative Technique
Operations were performed with the use of cardiopulmonary bypass and mild systemic hypothermia. Myocardial protection was achieved with crystalloid cardioplegia (St Thomas Formula II) before 2002, and thereafter with tepid blood cardioplegia. In patients requiring tricuspid repair, a Carpentier-Edwards annuloplasty ring (Edwards Lifesciences, Irvine, California) was used. Cardiopulmonary bypass times and aortic cross-clamp times were 82 ± 31 minutes and 60 ± 21 minutes, respectively. Two patients had previously undergone coronary artery bypass graft surgery, and 1, an aortic valve replacement.

Approach to the mitral valve was through standard left atriotomy. Mitral valve apparatus was analyzed, and prolapsed areas were identified. The repair of the posterior leaflet was performed according to the technique previously described [7]. The goal of the RRR approach is to correct PPL without leaflet resection and typically uses CV-4 expanded polytetrafluoroethylene (Gore-Tex; W.L. Gore & Associates, Flagstaff, Arizizona) suture neochordae to resuspend the free edge of the posterior leaflet. In a typical P2 prolapse, two pairs of artificial chordae are implanted in the fibrous portion of each papillary muscle with a figure-of-eight suture and then brought through the free edge of the prolapsing posterior leaflet. The number and placement of the artificial chordae may vary according to the extent and the location of the prolapsed area; however, the basic architecture of the subvalvular apparatus must be respected.

The goal is to correct the prolapse and transform the posterior leaflet into a smooth, regular, and vertical buttress parallel to the posterior wall of the left ventricle against which the anterior leaflet will come in apposition. Length of the artificial chordae is critical and determined to compensate for any excess tissue of the posterior leaflet so its free edge cannot move anteriorly toward the left ventricular outflow tract, but remains in the left ventricular inflow. Schematically, if there is no excess tissue, the length of the artificial chordae is selected so the free edge of the prolapsed area reaches the same level as the nonprolapsed reference point, usually P1. If there is excess tissue, the length of the artificial chordae is selected to bring the free edge of the prolapsed area to a lower level, typically 5 to 8 mm beneath the plane of the annulus, depending on the height of the posterior leaflet. Incisurae between P1 and P2 and between P2 and P3 are sutured with a 5-0 monofilament running suture if they are deep.

Ring annuloplasty was performed in 8 patients (3.6%) with a Carpentier-Edwards Classic ring and in 217 (96.4%) with a Carpentier-Edwards Physio ring after it became available (model 4450 and model 4400; Edwards Lifesciences). The size of the ring was selected according to standard criteria: intertrigonal distance and surface area of the anterior leaflet. After separation from cardiopulmonary bypass, the repair was evaluated by transesophageal echocardiography. Associated procedures are noted in Table 1.

Anticoagulation Therapy
Oral anticoagulation therapy (phenprocoumon) began 3 days postoperatively with a target international normalized ratio between 3.0 and 3.5. After 2 months, anticoagulant treatment was discontinued at the discretion of the referring physician, provided the patient was in sinus rhythm. At the time the study was undertaken, 43 patients were still on anticoagulants, and 80 were receiving antiplatelet therapy.

Follow-Up
Data on hospital mortality and complications were collected as part of follow-up. Long-term follow-up was completed between January and July 2007 through questionnaires and telephone contacts with patients and their referring physicians. Follow-up ranged from 3 months to 12.9 years; the median duration was 2.7 ± 2.2 years. Cumulative follow-up was 730 patient-years. Four patients (1.7%) were lost to follow-up.

Statistical Analysis
Computerized statistical analysis of the data was accomplished using the SPSS software (SPSS, Chicago, Illinois). Descriptive statistics are reported as the mean ± SD for continuous variables and as frequencies and percentages for categoric variables unless otherwise noted. Comparisons between groups were made with unpaired t tests for continuous variables and ² or Fisher exact tests for categoric variables. Estimates for long-term survival or freedom from morbid events were made by using the Kaplan-Meier method. The difference between Kaplan-Meier curves was evaluated by using the log-rank statistic. Age- and sex-matched survival estimates were obtained from the German Life Table, a downloadable spreadsheet developed by the "Statistisches Bundesamt" (available at: http://destatis.de). Results were reported according to the "Guidelines for Data Reporting and Nomenclature" [8].

	Results

Top Abstract Introduction Patients and Methods Results Comment Discussion Acknowledgments References

 
Operative Results
The height of the surface of coaptation, measured in 58 nonselected patients with echocardiography after being weaned from bypass, was 15 ± 2 mm.

Intraoperative echocardiography detected systolic anterior motion in 5 patients (2.2%). In 3 patients, systolic anterior motion was due to persistent excessive anterior motion of the free edge of the posterior leaflet; implantation of new shorter artificial chordae corrected the situation. In 2 patients, systolic anterior motion was associated with septal hypertrophy and was corrected with septal myectomy; in 1 of these, shorter artificial chordae were also needed.

Three patients died in hospital, for a mortality rate of 1.3%. Causes of death are reported in Table 3. There was 1 early death (0.6%) among the 178 patients with isolated mitral insufficiency, and none in the asymptomatic group.

Echocardiographic evaluation of the repaired mitral valve was performed in 225 patients before discharge or death. In 206 patients (92%), the valve was fully competent or showed only trace MR, in 14 patients (6%) grade 1 regurgitation was present, and in 5 patients (2%) MR greater than 1 was present. Mean MR was 0.12 ± 0.43 for the total group; 0.10 ± 0.43 and 0.13 ± 0.42 for the asymptomatic and symptomatic groups, respectively.

Survival
There have been 9 late deaths, 2 in the asymptomatic group and 7 in the symptomatic group. Figure 1 shows the Kaplan-Meier survival curve of all patients, compared with that of the general population matched for age and sex. The actuarial survival rate at 10 years was 88% ± 6%, whereas the expected survival was 87%. Figure 2 shows the Kaplan-Meier survival curves for the asymptomatic group and the symptomatic group. Ten-year survival was 97% ± 2% and 82 ± 9%, respectively (p < 0.05). The 10-year expected survival was 90% for the asymptomatic group and 82% for the symptomatic group (matched for sex and age). Causes of death are listed in Table 3.

View larger version (12K): [in this window] [in a new window]   Fig 1. Survival in the whole group of patients in comparison with that in the general population matched for age and sex. (Solid line = observed survival; dashed line = expected survival.)

View larger version (22K): [in this window] [in a new window]   Fig 2. Survival in the asymptomatic group (solid line) and symptomatic group (dashed line) in comparison with that in the general population matched for age and sex, as depicted by the thinner lines. (Dotted line = expected survival for asymptomatic group; dashed line = expected survival for symptomatic group.)

View larger version (19K): [in this window] [in a new window]   Fig 3. Reoperation in the whole group of patients (solid line) and in the asymptomatic group (short-dashed line) and symptomatic group (long-dashed line). (NS = not significant.)

Late Follow-Up
At the last follow-up, 74 patients (77%) in the asymptomatic group were in NYHA class I, 21 (22%) were in class II, and 1 (1%) was in class III. In the symptomatic group, 51 patients (48%) were in class I, 49 (45%) were in class II, 6 (6%) were in class III, and 1 (1%) was in class IV.

At the time of follow-up, interpretable echocardiography data from referring cardiologists could be obtained for 188 patients of the 203 surviving, nonreoperated-on patients. In the asymptomatic group, 87 patients (94%) presented with a fully competent valve or minimal MR (< grade 1); 6 patients (6%) had mild MR (< grade 2). Mean MR was 0.24 ± 0.62, not different from predischarge echocardiography (0.10 ± 0.41). In the symptomatic group, 85 patients (90%) presented with a fully competent valve or minimal MR (< grade 1), 7 patients (7%) had mild MR (< grade 2), and 3 patients had grade 3 MR; 2 of the 3 were subsequently scheduled for mitral valve reoperation. Mean MR in this group was 0.55 ± 0.94, significantly higher than the 0.13 ± 0.42 observed at the predischarge echocardiography.

	Comment

Top Abstract Introduction Patients and Methods Results Comment Discussion Acknowledgments References

 
Since the introduction of standardized techniques for mitral valve reconstruction by Carpentier [9], mitral valve repair has become the surgical treatment of choice for MR, providing better long-term survival than mitral valve replacement [6, 10]. Repair of PPL conventionally consists of leaflet resection and ring annuloplasty, which has shown excellent long-term durability [5, 6, 11–13]. However, the technique of leaflet resection as the undisputed procedure of choice for repair of PPL should be discussed. As conceptualized by Carpentier, the goal of mitral valve repair is to restore a good coaptation surface to ensure satisfactory function of the mitral valve [2]. As leaflet tissue is the primary component of the coaptation surface, it is logically appealing to preserve it. Moreover, posterior leaflet is composed of three scallops of different heights [14]. The highest portion (P2 scallop) sustains the greatest stress during systole [15]. Instead of resecting this most frequently involved area, the RRR approach targets correction of prolapse while preserving leaflet tissue to ensure a larger coaptation surface. Furthermore, it has been shown experimentally that by preserving the posterior leaflet tissue, coupled with the use of artificial chordae, the anatomic and dynamic relationships are maintained, allowing for the physiologic distribution of forces and stresses on valve components and the left ventricle [16]. Experimental data have confirmed that expanded polytetrafluoroethylene is a reliable material to replace mitral valve chordae [17].

The typical concern regarding artificial chordae is long-term durability. Artificial chordae for mitral valve repair in adults was first reported by David [18] in 1989 and then by Frater and colleagues [19]. Since then, studies have reported good and stable midterm and long-term results for mitral valve repair using this technique [20, 21]; Gore-Tex neochordae are now widely accepted for mitral valve repair.

Typically, echocardiographic results after mitral valve repair show a posterior leaflet with little or no mobility hanging vertically from the annulus and forming, as shown experimentally [22, 23] and clinically [24], a buttress against which the anterior leaflet comes into apposition. The goal of the RRR approach is to intentionally achieve this specific aspect and produce a large, smooth, regular, and vertical coaptation surface.

The subject of excess tissue, often associated with degenerative mitral disease, should be raised because it has been recognized as a major risk factor for postoperative systolic anterior motion [25], creating dynamic left ventricular outflow tract obstruction (Fig 4a) [26]. In such a situation, the combined height of the posterior leaflet (AB) and length of the chordae (BC) is too long, allowing the free edge of the posterior leaflet (B) to enter the left ventricular outflow tract. To avoid systolic anterior motion, the degree of correction of the PPL should be such that the coaptation surface remains vertical, posterior, and parallel to the posterior wall of the left ventricle in its inflow region. When adjusting the length of artificial chordae, it is necessary to take into account any excess tissue as described in the operative technique section (Fig 4b). This fundamental aspect of the RRR approach is fundamentally different from apparently similar techniques [20, 21, 27, 28].

View larger version (24K): [in this window] [in a new window]   Fig 4. The issue of excess tissue. (a) Dynamic left ventricular obstruction. (b) Correction by bringing the coaptation surface back into the left ventricular inflow region using new and shorter artificial chordae. (c) Correction by reducing the height of the posterior leaflet by a sliding plasty. (AB = height of the posterior leaflet; B = free edge of the posterior leaflet; BC = length of the chordae.)

Thorough analysis of the valve is necessary at the outset of the operation before deciding surgical strategy; the RRR approach may be preferred when quality and quantity of posterior leaflet tissue are adequate to achieve a smooth and regular surface. However, localized leaflet resection may be required to reconstruct the posterior leaflet and transform it into a smooth, vertical, and regular element. The extent and shape of the resection (triangular or quadrangular) should be guided by anatomical considerations: excessive and exuberant myxomatous degeneration can render the posterior leaflet irregular with bulging deformations that need to be resected to obtain a smooth and regular surface of coaptation; excess tissue, affecting not only the height of the posterior leaflet but more importantly its width, transforms the normally rectangular P2 into a trapezoidal element. The placement of the annuloplasty ring may result in folds of the posterior leaflet altering the coaptation surface smoothness; again, a localized resection to reshape the posterior leaflet is necessary. Accumulation of myxomatous material at the base of the posterior leaflet should be removed with leaflet resection, as it deforms and prevents the leaflet from hanging vertically, causing it to protrude anteriorly, increasing the risk of systolic anterior motion.

Frequently, a tailored and limited resection is enough to ensure a regular and smooth posterior leaflet; however, it may not totally correct the leaflet prolapse, and artificial chordae may be necessary. The repair of PPL, guided by anatomical considerations, becomes a patient-specific spectrum of techniques ranging from respect to resect. In our current practice, localized leaflet resection is needed in 30% to 35% of the patients, underlining the necessity of eclecticism in the choice of surgical techniques. It is worth noting that 102 patients (45%), although asymptomatic were treated as recommended in the scientific guidelines (class IIa indication) [30].

Our study shows that late survival after mitral valve repair for prolapse of the posterior leaflet is similar to that of the general population matched for sex and age. It confirms previous studies demonstrating that asymptomatic patients operated on for severe mitral valve regurgitation have significantly better survival than do symptomatic patients [11, 31]. The survival rate of the asymptomatic group was somewhat better than expected, possibly owing to selection methods: asymptomatic surgical candidates are selected only if free of other diseases.

The perennial concern with mitral valve repair is its long-term durability and the need for reoperation. The freedom from reoperation rate of 93% at 10 years may seem lower than that observed in some studies [6, 12], but comparison of reoperation rates from one center to another may be misleading. More importantly, the 93% freedom from reoperation at 10 years with the RRR approach is not significantly different from the 95% at 6 years obtained with standard quadrangular resection in our institution, using the same methodology [5]. It is interesting to note that patients in the asymptomatic group show a higher rate of freedom from reoperation than do patients in the symptomatic group, although not significantly so. Among the 10 reoperations, only 2 cases were directly related to the technique used (due to artificial chordae detachment), whereas in the 8 other patients, the causes of reoperation could be seen after any type of mitral valve repair.

Echocardiographic follow-up confirms the stability of the repair over the years, since 94% and 90% of the patients in the asymptomatic and symptomatic groups, respectively, show no or minimal MR at the time of follow-up. These results, supported by other studies [6, 11, 19, 20], reflect different outcomes from those published by Flameng and associates [32]. Echocardiographic data show a great stability of the repair over time, although there is a worsening of the MR in the symptomatic group in contrast to the asymptomatic group, a finding not observed in other studies [11].

The linearized rate of thromboembolic complications of 2.1% patient-years is higher than that found in other studies [33] and could be related to the delayed administration of anticoagulation that was started on the third postoperative day.

In conclusion, the RRR approach offers a logical method to treat PPL, increasing the technical strategies available for mitral valve repair. It is a safe method, allowing pursuit of another technique at any time, as nothing is resected or irreversibly altered, and it shows the same stability of results as the classical approach. The use of this approach has changed our minds and strategies for repairing PPL; instead of focusing on the site and extent of resection, our goal is to preserve and remodel the posterior leaflet to create the best surface of coaptation possible.

	Discussion

Top Abstract Introduction Patients and Methods Results Comment Discussion Acknowledgments References

 
DR DANIEL H. DRAKE (Traverse City, MI): I congratulate you on your excellent presentation. I have borne witness to Dr Perier's work for nearly a decade and it is in fact superb. My question is as follows: For those patients suffering from Barlow's disease, Ehlers-Danlos, or Marfan's syndrome, the tensile strength of the tissues is decreased. Despite a thickened appearance, the leaflet and chordal tissue is actually weak. In the presence of excessive leaflet tissue some have advocated solutions based on artificial chords and large or even oversized rings with no attempt to return the leaflet surface area or annulus to more normal dimensions. Typically, the fear is that any annular reduction in a patient with Barlow's disease will result in systolic anterior motion.

The Young-Laplace Law dictates that larger surface areas increase tension on all valvular structures. Increased tension on weak tissue is obviously not ideal. Therefore, it must be concluded that at least partial restoration of normal anatomic dimensions should be important when correcting insufficiency from excessive but weak valvular tissue. I have consistently performed leaflet resection combined with near normal size ring annuloplasty when confronted with the enlarged annulus and excessive tissue from Barlow's disease or similar conditions. The intermediate-term freedom from systolic anterior motion, reoperation, or recurrent regurgitation greater than 1+ is approximately 98%.

My question is therefore: in your practice, are there circumstances when you consider resecting leaflet tissue not only to restore normal functional anatomy but also to restore more normal size dimensions, thus decreasing tension on intrinsically weak tissue?

DR PERIER: Doctor Drake, thank you very much for your question. My intention is not to say that you have to respect all the time. My intention is to clearly say that my surgery is driven by a goal, and the goal is to have a smooth and regular surface of coaptation, which is vertical in the inflow tract of the left ventricle. If to reach your goal, you have to resect, then resect. If, for instance, you have myxoid degeneration that makes exuberant pockets that will lead to an irregular surface of coaptation, resect. If you have too much tissue laterally, resulting in folding of the posterior leaflet, after implantation of the ring, that is to say irregular surface of coaptation, you have to resect. So it is not "resect or respect." It is respect whenever you can respect. But there is still a place for leaflet resection to reach the goal.

DR DRAKE: Thank you for the clarification. Again, I thoroughly enjoyed your presentation.

DR BOBBY KONG (Ann Arbor, MI): It is wonderful to have so many experts of artificial chordal technique in this room here today. I would like to ask a technical question as to what kind of sutures were used, size, do you use pledgeted or not, and can you share with us how you tie the knots without slipping?

DR PERIER: I use CV-4 Gore-Tex sutures. I don't use pledgeted suture because I do not think that it is necessary, the tissue is strong enough. I don't have a special trick to tie the knots, it requires a little practice to tie air knots. I know that people are bothered by tying the knots because they may slip. To avoid this phenomenon, another very good technique has been developed by Fred Mohr, and that is to use preformed loops according to premeasured length. So you have a choice. Those may be seen as technical details. The most important thing is more the concept than the technical details used to reached the goal.

DR ROBERT A. E. DION (Genk, Belgium): Patrick, it has been a pleasure to work with you since so many years in the European Master, so I probably half know the answer to my question. I would like you to be precise here whether there are cases in which you do not apply your technique because of the quality of the posterior leaflet?

DR PERIER: This is what I tried to explain to Dan Drake. What I learned over the years and the change of my strategy is that my goal changed. My goal is to try at the end of the operation to have the best surface of coaptation as possible, regular, smooth; and if I cannot have this because the posterior leaflet is not adequate, the tissue is not right, then I do not hesitate to resect in order to reach my goal. The problem is not respect or resect, the pragmatatic approach is to respect the tissue as much as you can to reach your goal. I try to be open-minded and to be eclectic in the choice of my techniques.

DR DION: I have no doubt about it. Thank you very much.

DR WALAA A. SABER (Cairo, Egypt): Thank you very much, Dr Perier, for this nice presentation. You said respect when applicable. If you are going to resect, what do you think about this technique of resecting the triangular shape with the apex toward the annulus to avoid this annular plication?

DR PERIER: I must confess that when I resect, I tend to resect as little as I can, and usually I do a triangular resection.

DR FRIEDRICH WILHELM MOHR (Leipzig, Germany): Number one, I would like to compliment you, Patrick. Nobody can explain it that well with your schematic drawings, and you are a master of teaching, and thank you very much for this. And I also would like to support your technique of repair; we have been following the same principle during the last years. I also liked your comment you just made that sometimes you also have to resect. I would also agree with that.

We do have a series of more than 600 patients with chordal replacement for the posterior leaflet. We think from these that one also enhances the number of possible repairs, because sometimes there are patients with massive prolapse of P1, P2, P3, and if you proceed and resect, there is nothing left at the PML. I am pretty sure you know these cases, and could you comment on that? Also, how many chords do you place per segment?

DR PERIER: Thank you very much, Friedrich, for your questions and your very nice comments. I think that this technique is helping the surgeon and hence increasing the possibility of repairs. For instance, if you have a very large prolapsed area of the posterior leaflet, you may do either a limited resection, or no resection at all, and suspend with artificial chordae the remaining free edge of the posterior leaflet that may still prolapse. It expands the possibilities of repair in these difficult situations. It makes repair easier, and more importantly, it expands the technical possibilities. Colleagues who have trouble to do repairs because there are too many questions, too difficult, may be tempted by this technique, which is simple and reproducible. And to me, what has been the most interesting, again, is the change in the set of mind concentrating on the goal, the reconstruction of the best surface of coaptation, rather than on the implementation of a specific technique.

	Acknowledgments

Top Abstract Introduction Patients and Methods Results Comment Discussion Acknowledgments References

 
The authors thank Isabelle Tran, John Lunsford, and Jeff Swanson, MD, for their editorial assistance.

	References

Top Abstract Introduction Patients and Methods Results Comment Discussion Acknowledgments References

 

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