Mitral Valve Repair: Five Techniques for 95% Repair

Current American Heart Association/American College of Cardiology guidelines state that mitral valve repair for asymptomatic patients with preserved left ventricular function is reasonable when the likelihood of a successful and durable repair is greater than 95%, with an expected mortality rate of less than 1% when performed at a Heart Valve Center of Excellence (1). Several reports have demonstrated that repair rates for degenerative mitral valve disease can approach 100% (2, 3).

This video demonstrates a systematic approach to mitral valve repair, which is utilized at the Cleveland Clinic to repair the vast majority of degenerative mitral valve cases. This approach begins with identification of the anatomic location(s) of prolapse and the application of five core repair techniques: triangular resection, sliding repair, artificial chordae, commissuroplasty, and annuloplasty.

For posterior leaflet prolapse, the choice of repair technique is dictated primarily by the predicted risk of postoperative systolic anterior motion (SAM). For valves with low SAM risk, simple triangular resection is appropriate. In cases where the risk of SAM is high, a sliding repair can be performed to facilitate a more posteriorly positioned coaptation point. Artificial chordae can be used in either situation, as the position of the coaptation point can be adjusted by the length of the chordae.

Anterior leaflet prolapse is always repaired with artificial chordae. Commissural prolapse can be repaired with commissuroplasty. The authors have found that up to one third of the valve area can be closed without causing significant mitral valve stenosis.

In nearly all cases, degenerative mitral valve repair is completed with a posterior annuloplasty using a flexible annuloplasty band. When utilized according to this systematic approach, the authors believe that a successful and durable repair can be achieved in the vast majority of degenerative mitral valve cases.

References

1. Nishimura RA, Otto CM, Bonow RO, et al. 2017 AHA/ACC focused update of the 2014 AHA/ACC guideline for the Management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2017 Jun 20;135(25):e1159-e1195.
2. Gillinov AM, Mihaljevic T, Javadikasgari H, et al. Early results of robotically assisted mitral valve surgery: analysis of the first 1000 cases. J Thorac Cardiovasc Surg. 2018 Jan;155(1):82-91.
3. Castillo JG, Anyanwu AC, Fuster V, Adams DH. A near 100% repair rate for mitral valve prolapse is achievable in a reference center: implications for future guidelines. J Thorac Cardiovasc Surg. 2012 Aug;144(2):308-312.