Advantages of Mitral Valve Repair Over Replacement
It is well accepted that the majority of patients with degenerative mitral valve disease who require surgery will have an improved quality of life with less morbidity and better long-term survival with valve repair as opposed to replacement.1 This is attributable primarily to prosthesis-related morbidity, including higher reoperation rates, greater risk of endocarditis, and the need for anticoagulation with mechanical valves. Anticoagulation is particularly problematic for young, active patients and women in the child-bearing age group.
Therefore, when feasible, repair is preferred to replacement. The two keys to repair feasibility are the condition of the mitral valve and the experience of the surgeon. In most cases, mitral valve repair is technically no more complex than valve replacement. Mastery of only a handful of repair techniques enables repair of more than 90 percent of degenerative valves. A successful mitral valvuloplasty for degenerative disease provides most patients with an extremely durable valve, with many patients remaining free of reoperation 30 years after valve repair.2
The choice of repair technique for a given mitral valve depends upon the site of prolapse. We will present, in sequence, repair options for posterior, anterior, commissural, and bileaflet prolapse.
Posterior Leaflet Prolapse
Approximately 75 percent of patients with mitral regurgitation (MR) caused by degenerative disease have isolated prolapse of the posterior leaflet, most commonly the P2 segment (middle scallop).3 Several techniques have been developed to deal with this anatomical site of prolapse.
This is the classic technique for managing P2 prolapse, with or without a sliding repair.4 The sliding repair was developed to reduce the risk of postrepair systolic anterior motion (SAM) in the setting of excessive leaflet tissue and/or a small, hyperdynamic left ventricle.5 The classic quadrangular resection, which includes annular plication, is rarely employed today and has been largely replaced by a triangular resection technique. Similarly, a folding repair technique has replaced the sliding repair.