Translocated anterior mitral leaflet sparing is a viable treatment option for both degenerative and functional mitral valve disease.
Academic Article
Overview
abstract
BACKGROUND: We present a technique for mitral valve (MV) replacement that preserves the anterior mitral leaflet (AML) using complete chordal-sparing mitral valve replacement (CCS-MVR), which maintains the architecture of the left ventricle. This technique is beneficial for patients with functional, degenerative, and infective MV disease who were unable to undergo MV repair. The objective of this study is to ascertain the most efficacious treatment for MV disease. Furthermore, the study will contribute to international guidelines for this procedure and provide data on its efficacy in treating MV disease. METHODS: We performed MV replacement surgery on 161 patients, maintaining the integrity of the entire subvalvular chordae tendineae apparatus. Of these cases, 92 (57.1%) were degenerative, 58 (36.0%) were functional, 9 (5.6%) were infective, and 2 (1.2%) were rheumatic. Of the 93 patients with complicated MV disease, massive calcification was observed in 59 cases (36.6%) and mitral annular disjunction (MAD) was observed in 25 cases (15.5%) while endocarditis with posterior annular abscess was observed in 9 cases (5.6%). The anterior leaflet is detached from its connection to the annulus along the entire extent from the posterior commissure to the anterior commissure. In cases of excess tissue, a section of the free edge of the translocated leaflet must be removed. This must preserve a small section of the edge and the entire chordae tendineae unit. A CCS-MVR requires 24 to 28 individual sutures in routine cases. The AML was reinserted using 12 to 14 single sutures in this specific order: posterior annulus, posterior mitral leaflet, AML, and prosthetic valve. RESULTS: The 30-day mortality rate was 8.7%, based on 14 cases. Ten patients, representing 5% of the total, required reoperation after the initial procedure. Out of 140 patients,74 (52.8%) experienced LV reverse remodeling at the six-month follow-up. Female patients exhibited a significantly higher rate of LV reverse remodeling (71% vs. 29%, P<0.001) compared to male patients. Patients with mitral annular calcification and MAD demonstrated significantly higher rates of left ventricular reverse remodeling compared to patients with coronary artery disease (CAD). We can conclude with certainty that male gender, CAD, atrial fibrillation, and preoperative left ventricular end-diastolic volume indexed (LVEDVI) are significant predictors of LV remodeling. We found that the median survival time after CCS-MVR was 39.5 months. The results of the multivariable analysis revealed that patients with MAD had significantly worse survival rates than those without. CONCLUSIONS: For patients presenting with severely calcified posterior mitral annulus, complicated Barlow disease with MAD, or endocarditis involving the posterior annulus, the AML is consolidated with the posterior mitral leaflet to form a neo-annulus. This procedure is safe and effective for a wide range of simple and complex MV pathologies. Its efficacy is unquestionable. It preserves the complete architecture of the left ventricle, avoiding dilatation and promoting reverse remodeling.
