J. Maxwell chamberlain memorial paper for adult cardiac surgery
Surgical Repair of Posterior Mitral Valve Prolapse: Implications for Guidelines and Percutaneous Repair

Presented at the Forty-fifth Annual Meeting of The Society of Thoracic Surgeons, San Francisco, CA, Jan 26–28, 2009. Winner of the J. Maxwell Chamberlain Memorial Award for Adult Cardiac Surgery.
https://doi.org/10.1016/j.athoracsur.2009.12.070Get rights and content

Background

Guidelines recommend early surgery for mitral regurgitation (MR) provided repair can be accomplished safely and consistently. However, many patients with degenerative disease are not referred for surgery or undergo replacement rather than repair. Data documenting early and long-term results of surgical repair of posterior prolapse, the most common lesion, are essential to broaden application of repair techniques and provide direction for percutaneous valve repair. This study provides data on long-term survival and valve function after repair of posterior leaflet prolapse.

Methods

Of 3,383 patients undergoing surgery for isolated posterior leaflet prolapse, repair was performed in 97%; 3,074 underwent standard quadrangular resection with annuloplasty. Follow-up for survival averaged 6.5 ± 4.5 years and for reoperation, 4.0 ± 3.9 years. Analysis of 4,913 echocardiograms for recurrent MR was performed in a subgroup of 2,575 patients.

Results

There were two hospital deaths (0.07%), and 15-year survival was 76%, superior to the age- and sex-matched US population. At 10 years, freedom from mitral reoperation was 97%, and 77% had no or 1+ MR; 11% had 3+ or 4+ MR. Repair durability was jeopardized by failure to use a prosthetic annuloplasty, left atrial enlargement, and left ventricular remodeling and dysfunction.

Conclusions

Mitral valve repair for posterior prolapse is a low-risk, durable surgical procedure. The repair must address both leaflet and annulus. Recurrent MR that is moderately severe or severe is uncommon in the decade after operation. These data support recommendations for early surgery and demonstrate that complete repair addresses multiple components of the valve, providing direction for percutaneous approaches.

Section snippets

Study Population

From January 1985 to January 2008, 4,258 patients with isolated degenerative mitral valve disease underwent primary isolated mitral valve repair at Cleveland Clinic. Mitral regurgitation was the primary indication in all. Patients having previous or concomitant operations for coronary artery disease, aortic valve disease, hypertrophic cardiomyopathy, or ascending aortic aneurysm were excluded. Results in an early subgroup of these patients were reported previously [5]. Of the 4,258 patients,

Survival

There were 2 hospital deaths (0.07%; CL, 0.03%, 0.2%). Overall unadjusted survival estimates at 1, 5, 10, and 15 years were 99%, 96%, 87%, and 76%, respectively. These figures compare favorably with expected survival of the age- and sex-matched US population, and this was true across all age groups (Fig 3A). Instantaneous risk of death (hazard function) resolved into three phases: a rapidly declining early hazard phase dominating to almost 6 months, a constant hazard phase dominating from 6

Comment

Surgical mitral valve repair for posterior leaflet prolapse is associated with low operative risk, excellent long-term survival, and long-lasting durability. Best results are obtained when repair is performed before onset of symptoms or change in cardiac structure or function. Standard repair techniques that address both the leaflets and the annulus are necessary to achieve these results in patients with severe MR.

References (33)

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    The 10- and 20-year survivals were 79% and 62%, and freedom from reoperation at 10 and 20 years was 90% and 82%, respectively. An additional series reported by the Cleveland Clinic in 2010 consisted of 3074 patients with isolated posterior MV leaflet prolapse who underwent an MV repair with quadrangular resection and annuloplasty of which more than 60% were repaired in a minimally invasive fashion.18 The in-hospital mortality was 0.1%, and 1-, 5-, 10-year survival rates were 99%, 96%, and 87%, respectively, superior to the age- and sex-matched US population.

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