Clinical impact of the repair technique for posterior mitral leaflet prolapse: Resect or respect?

Abstract

Background and Aim Leaflet resection and chordal reconstruction are established repair techniques for posterior mitral valve (MV) prolapse. This study aimed to compare the clinical results of the resect and respect approaches, with a particular focus on MV hemodynamics. Methods Overall, 291 patients who underwent elective MV repair for isolated posterior leaflet prolapse between 2012 and 2020 were enrolled. Patients who underwent leaflet resection alone were classified as the “resection” group (n = 166), while patients who underwent neochordal replacement with/without limited leaflet resection were classified as the “respect” group (n = 125). Early postoperative MV hemodynamics and midterm repair durability were compared between the groups. Results The annuloplasty ring size was significantly larger in the respect group than in the resection group (31.0 ± 2.1 vs. 30.4 ± 2.0 mm, p = .028). The respect group showed significantly lower mean MV gradient (2.6 ± 1.1 vs. 3.0 ± 1.4 mmHg, p = .03) and larger effective orifice area (EOA) (1.86 ± 0.48 vs. 1.66 ± 0.47 cm2, p < .001) than the resection group. Multivariable analysis identified the respect approach, younger age, female sex, larger ring size, and partial band as independent determinants of larger EOA. The rate of freedom from moderate or greater recurrent mitral regurgitation 5 years postoperatively was 90.9% in both groups. Conclusions The respect approach allowed for a lower MV gradient and a larger EOA than the resection approach, which is possibly due to the capability of implanting a larger annuloplasty ring.

State-of-the-Art Review: Technical and Imaging Considerations in Novel Transapical and Port-Access Mitral Valve Chordal Repair for Degenerative Mitral Regurgitation

“…Additionally, a small difference in transmitral gradient (2.5 vs. 2.8 mmHg, p = 0.0004) and orifice area (3.2 vs. 3.0 cm2, P = 0.002) was observed in favor of chordal replacement ( 24 ). The latter was also confirmed by a recent study of Sakaguchi et al ( 26 ), who showed a lower mean MV gradient of 2.6 ± 1.1 vs. 3.0 ± 1.4 mmHg ( p = 0.03) and a larger effective orifice area of 1.86 ± 0.48 vs. 1.66 ± 0.47 cm2 ( p < 0.001) in favor of chordal replacement. Importantly, Sakaguchi also demonstrated that the mean MR grade before discharge was significantly lower in the chordal replacement group than in the resection group (0.22 ± 0.41 vs. 0.35 ± 0.49, p = 0.018), based on a combined amount of 291 patients who underwent elective MV repair for isolated pMVL prolapse between 2012 and 2020 ( 26 ).…”

Respect or resect: A single strategy does not fit all

“…In this article, Sakaguchi et al 5 describe their results in two groups of patients with PL prolapse. Some patients underwent resection (resection group) and others chordal replacement with/out limited resection (respect group).…”

“…What is important is the long‐term result and the quality of life. Sakaguchi et al 5 followed this line given that some of their patients included in the respect group had limited resection, as a result of some common sense applied during surgery.…”

“…The problem exists, but long‐term results reported by Sakaguchi et al 5 are limited to MR recurrence. We have no idea if the early benefit of a lower gradient and a higher mitral orifice in the respect group translated into a better clinical outcome.…”

Respect or Resect: A Single Strategy Does Not Fit All

“…In this paper, Sakaguchi et al 5 describe their results in two groups of patients with PL prolapse. Some patients underwent resection (resection group) and others chordal replacement with/out limited resection (respect group).…”