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Key Concepts

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  • Advantages of repair vs replacement

    • Degenerative disease of the mitral valve is a surgically treatable entity, when repaired leading to improved quality of life and better long-term survival as opposed to replacement.

  • Keys to repair

    • Condition of the mitral valve

    • Experience of the surgeon

  • Repair techniques

    • Choice of repair depends on the site of prolapse.

    • Tailor repair to site and mechanism determined by perioperative echocardiogram

  • Surgical approaches

    • Range from complete sternotomy to robotically assisted

    • Choice of approach should be tailored to valve pathology determined preoperatively.

    • Standard, reproducible repair techniques should be employed.

  • Outcomes

    • Durability of repair is measured by freedom from reoperation and recurrence of MR.

    • Operative risk is less than 1 percent.

    • Long-term survival rates at 10, 15, and 20 years are 92, 76, and 48 percent, respectively

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Advantages of Mitral Valve Repair Over Replacement

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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.

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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

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Repair Techniques

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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.

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Posterior Leaflet Prolapse

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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.

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Quadrangular Resection
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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.

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Triangular Resection
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