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Original research article
Subannular reconstruction in secondary mitral regurgitation: a meta-analysis
  1. Eva Karolina Harmel,
  2. Hermann Reichenspurner,
  3. Evaldas Girdauskas
  1. Department of Cardiothoracic Surgery, University Heart Center Hamburg, Hamburg, Germany
  1. Correspondence to Professor Evaldas Girdauskas, Department of Cardiovascular Surgery, University Heart Center Hamburg, Hamburg 20251, Germany; e.girdauskas{at}


Objective Mitral valve repair using an undersized complete annuloplasty ring in secondary mitral regurgitation with restricted leaflet motion during systole (Carpentier’s surgical classification of mitral valve pathology: type IIIb) only inadequately addresses the underlying left ventricular disease. This may lead to an ongoing ventricular remodelling and progressive papillary muscle displacement with increasing leaflet tethering. Several subannular techniques have been proposed to counteract the reoccurrence of mitral regurgitation after mitral valve repair. We aimed to evaluate the potential additive effect of such subannular techniques on the late reoccurrence rate of secondary mitral regurgitation.

Methods Systematic literature review and meta-analysis were performed on PubMed, Embase and Google Scholar for studies published up to March 2016 and reporting late reoccurrence of mitral regurgitation after mitral valve repair using standard annuloplasty (control group) versus annuloplasty with subannular correction (study group) cohorts. Primary endpoint was late reoccurrence of mitral regurgitation ≥2 after surgical mitral valve repair, as defined by follow-up echocardiography.

Results The cumulative number of 1093 patients in 12 included studies served as our study population. A total of 743 patients underwent combined mitral valve repair including annuloplasty and subannular manoeuvre (ie, study group), while the remaining 350 patients underwent an isolated ring annuloplasty (ie, control group). Secondary mitral regurgitation was caused by ischaemic heart disease in 733/743 patients in the study group and 334/350 patients in the control group. Mean echocardiographic follow-up was 42.7±13.9 months. Pooled outcome analysis demonstrated that the combination of subannular repair with ring annuloplasty was associated with a significantly lower reoccurrence rate of mitral regurgitation ≥2 as compared with annuloplasty alone (OR 0.27, 95% CI 0.19 to 0.38, P=0.0001).

Conclusion The combination of subannular reconstruction and mitral valve annuloplasty is associated with a lower late reoccurrence of mitral regurgitation after surgical mitral valve repair, as compared with annuloplasty alone.

  • mitral regurgitation
  • meta-analysis
  • valve disease surgery

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  • Contributors EKH and EG planned the meta-analysis. EKH did the primary literature research. EKH und EG did the detailed review of all eligible papers. Statistical analyses were performed by EKH and reviewed by EG. The manuscript was written by EKH and EG. HR did the proof reading of the manuscript and was a valuable contributor for the introduction and discussion. HR, EG and EKH are responsible for the overall content as guarantors.

  • Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Presented at The abstract was presented at the 46th Annual Meeting of the German Society of Thoracic, Cardiac and Vascular Surgery (DGTHG) in Leipzig (14 February 2017).

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