Chapter 35: Mitral Valve Repair

INTRODUCTION

It can be reasonably argued that the very dawn of cardiac surgery began with a mitral valve repair. On May 20, 1923, Dr Elliot Carr Cutler (Fig. 35-1) performed the world’s first successful mitral valve repair at the Peter Bent Brigham Hospital in Boston, Massachusetts.¹ Dr Cutler carried out a transventricular mitral valve commissurotomy with a neurosurgical tenotomy knife on a critically ill 12-year-old girl. His choice of instrument was likely influenced by Dr Harvey Cushing who was surgeon-in-chief at the time. A new era in surgery was introduced as well as the reality of mitral valve repair.² Cutler had worked assiduously on this problem in the Surgical Research Laboratories of Harvard Medical School before turning his attention to this critically ill patient. Subsequent attempts at this operation using a device to cut out a segment of the diseased mitral valve resulted in several deaths from massive mitral regurgitation and Cutler eventually abandoned the procedure.³ Of Cutler’s contemporaries, Henry Souttar of England performed a single successful transatrial finger commissurotomy in 1925, but received no further referrals.⁴ After Souttar, there remained little activity in mitral valve repair until the 1940s when Dwight Harken, then the Chief of Cardiothoracic Surgery at the Peter Bent Brigham Hospital, published his groundbreaking series of valvuloplasty patients for mitral stenosis.⁵ Dr Charles Bailey of Philadelphia also published a concomitant series of a similar large group of patients.⁶

That early era focused on mitral stenosis created by rheumatic heart disease, which was extremely common at the time. Surgical treatment of mitral regurgitation for prolapse was first introduced in the 1950s^7-9 but with limited success. Subsequent decades would see the visionary concepts of surgical leaders such as Alain Carpentier, Dwight McGoon, Carlos Duran, and others come to the fore as their visionary ideas for mitral valve reconstruction began to take hold and excellent results were reported. Like many other groundbreaking ideas, their concepts were met with resistance that has gradually dissipated as long-term results by these surgeons have been validated. The concept that repair of mitral regurgitation might serve to further damage a weakened left ventricle (LV) by eliminating the “pop-off” mechanism¹⁶ of the regurgitant valve. This proved a significant barrier to referral that only in the past few decades has been overcome. What has now become firmly established is the significant contribution to overall left ventricular function of the papillary muscle-annular interaction.¹⁷ As a result of these contributions, mitral valve repair, if technically possible, has now become recognized as the procedure of choice for mitral valve pathology of virtually all etiologies, to the extent that mitral valve repair is always considered first in virtually any clinical situation in which the mitral valve is regurgitant.

ANATOMY OF THE MITRAL VALVE