Author name: Actis Dato Guglielmo M., MD, Actis Dato Giulia, MD
Affiliation: Cardiac Surgery, Mauriziano Hospital Umberto I, Turin,
Italy
Short Title: Anterior Leaflet Repair
Corresponding author details: Cardiochirurgia, Ospedale Mauriziano,
largo Turati, 10125 Torino, Italia
Stajanovic and coll. compared data of 74 patients operated on for mitral
valve repair in anterior leaflet prolapse with a randomly assigned 74
cases of posterior repair of mitral valve in a period of 11 years in the
same Center (1).
Repair of the mitral valve historically represents a cornerstone of
cardiac surgery in its beginnings. Hundreds of thousands of patients
were operated on beating heart for rheumatic disease in case of valve
stenosis trough commissurothomy (2). In the following years advent of
extracorporeal circulation, has also become possible repair in cases of
mitral insufficiency (3). This stimulated surgeons to perform this type
of surgery on an increasing number of patients with good results (4).
Valve repair in the event of failure related to a posterior leaflet
disease has been standardized during the 1990s. This has allowed to
obtain excellent results especially when associated with annuloplasty by
using a ring (5).
Vice versa, anterior leaflet disease historically suffered from a lower
incidence of success in the follow-up and this discouraged the use of
repair techniques in the past. Undoubtedly, surgical techniques
necessary to obtain a good immediate and remote result after an anterior
leaflet repair are more complex and not always easily reproducible as
they are less standardized.
Minimum intervention volume to be performed by a surgeon who deals with
this type of pathology is considered to be at least 25 repairs per year.
David and collaborators demonstrated that isolated anterior mitral
prolapse repair in a median follow-up of 10 years is a significant
predictor of recurrent regurgitation and re-operation even when
performed by a single, more experienced surgeon (6). Particular care
should therefore be taken when interpreting insignificant differences in
the risk of re-operation after mitral repair in the anterior and
posterior leaflet.
With this paper Stojanovic and collaborators encourage a wider use of
anterior leaflet repair if performed in specialized centers of
excellence and with significant surgical volumes. Nevertheless presence
of atrial fibrillation or dysfunction of left ventricle appears to be
indepedent preoperative factors of failure in case of involvement of the
anterior leaflet.
This would therefore lead to being more aggressive in the treatment of
this pathological condition in the earlier stages of the disease.
Authors should be congratulated for having highlighted and encouraged to
always evaluate the potential benefit of mitral repair even in the
presence of a defect involving the anterior leaflet.
In experienced hands anterior leaflet repair can be effective and safe
and should theoretically not limit a conservative technique instead of a
replacement.
1 Stojanovic I et al Clinical and echocardiographic predictors of the
anterior mitral leaflet repair failure. J Card Surg 2022
2 Bajaj SS, Fann JI. History of Surgery for Mitral Stenosis: John Mayow
to Charles Bailey. Ann Thorac Surg. 2022 Jun;113(6):2097-2101.
3 Kay JH, Tsuji HK, Redington JV, Yokoyama T. Surgical Treatment of
Mitral Insufficiency
Calif Med. 1967 Oct; 107(4): 311–314.
4 Actis Dato GM, Zingarelli E, Flocco R, Tomasello A, Del Ponte S, Punta
G, Forsennati P, Casabona R. A 43-year follow-up after mitral valve
repair. J Cardiovasc Surg (Torino). 2009 Jun;50(3):415-6.
5 Deloche A, Jebara VA, Relland JY, Chauvaud S, Fabiani JN, Perier P,
Dreyfus G, Mihaileanu S, Carpentier A.
Valve repair with Carpentier techniques. The second decade. J Thorac
Cardiovasc Surg. 1990 Jun;99(6):990-1001; discussion 1001-2.
6 David TE, Armstrong S, McCrindle BW, Manlhiot C. Late outcomes
of mitral valve repair for mitral regurgitation due to degenerative
disease. Circulation. 2013 Apr 9;127(14):1485-92.