Sir Thomas Lauder Brunton, a Scottish physician, first introduced the concept of surgical repair of the mitral valve in 1902.1 Twenty-one years later, Elliot Cutler, the future Moseley Professor of Surgery at the Peter Bent Brigham Hospital in Boston, performed the world's first successful mitral valve operation in 1923 by carrying out a transventricular commissurotomy with a neurosurgical tenotomy knife. 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 a critically ill, bed-bound 12-year-old girl, performing mitral valvulotomy on May 20, 1923. With that seminal operation, the idea of surgically restoring normal anatomy to the pathologic mitral valve came to fruition. Subsequent attempts at transventricular valvulotomy with a cardiovalvutome to produce graded mitral regurgitation resulted in several deaths 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 Dwight Harken, then the Chief of Cardiothoracic Surgery at the Peter Bent Brigham Hospital, published his groundbreaking series of valvuloplasty patients for mitral stenosis5 concomitantly with Charles Bailey in Philadelphia.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 1950s7–9 but with limited success. Later, in the '60s, '70s, and '80s, the visionary concepts and ideas disseminated by Carpentier,10 McGoon,11 and Duran,12 and later promulgated by others,13–15 stimulated the field. Initially, those ideas, like any other groundbreaking idea, were met with resistance that has gradually dissipated as long term results by these surgeons have been validated. In particular, the idea that repair of mitral regurgitation might damage a weakened left ventricle by eliminating the left atrium as a low-resistance “pop-off” valve16 proved a significant barrier to referral that only in the past decade 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.
This chapter will focus on repair of the myxomatous, degenerated valve with some consideration of the repair of the rheumatic mitral valve. Repair of ischemic or infected mitral valves is presented in detail in Chapters 29 and 43, respectively. Detailed pathophysiology of the mitral valve is presented in Chapter 40 and detailed echo findings are shown in Chapter 11 by Sarano.