Repair of the anterior mitral leaflet prolapse

Abstract

Repair of anterior mitral leaflet prolapse is one of the most challenging aspects in mitral valve repair surgery. In this review, we discuss the various techniques developed over the past three to four decades for the repair of anterior mitral leaflet prolapse, debate the pros and cons of each and compare their results, keeping reoperation for recurrent mitral regurgitation as the focal point of follow-up. At our center, chordal replacement with artificial expanded polytetrafluoroethylene sutures in the form of premeasured loops is the most commonly used technique for repair of anterior mitral leaflet prolapse for the past decade. We recommend and provide justification for the use of this technique, especially when mitral valve repair is performed through a minimally invasive approach. We believe that the trend towards a minimally invasive approach for mitral valve repair will exponentially increase in the next 5–10 years, at least until percutaneous techniques, if at all, become more reliable and safe.

Keywords::

• anterior leaflet prolapse
• chordal replacement
• mitral valve
• surgical techniques

Financial & competing interests disclosure

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

No writing assistance was utilized in the production of this manuscript.

Key issues

• ‘Repair of anterior mitral leaflet prolapse is challenging’, is a statement commonly encountered in current surgical literature on the treatment of mitral valve regurgitation. However, with the availability of a variety of surgical options described above, this challenge can be overcome with the correct use of these techniques.

• Current literature suggests that chordal transposition, edge-to-edge repair and chordal replacement are surgical techniques that have similar long-term results. However, the former two techniques result in reduction of the mitral orifice area due to leaflet resection and creation of a double orifice mitral valve, respectively.

• Chordal replacement does not reduce the mitral orifice area as it follows the principle of ‘respect rather than resect’. It addresses the pathology of anterior leaflet prolapse in the best possible way and provides a very good functional and morphological repair that mimics the native valve and hence provides excellent long-term durability. We believe that chordal replacement is one of the most important factor for making anterior leaflet prolapse highly reparable in our institution. Chordal replacement with premeasured loops not only simplifies the technique, but also makes it reproducible and safe. It enables surgeons to achieve near 100% repair rates for anterior mitral leaflet prolapse, which would otherwise require complex reconstructive techniques.

• Finally, the loop technique makes this ‘so-called’ challenging repair safely and reliably possible even through a minimal access right anterior thoracotomy, which offers an excellent view of the anterior mitral leaflet.

Notes