Mitral valve reconstruction in a patient with Libman-Sacks endocarditis: a case report.

A symptomatic young woman with newly diagnosed systemic lupus erythematosus and secondary antiphospholipid syndrome with elevated anticardiolipin antibodies presented with small nodules on both leaflets of the mitral valve and with a consecutive high-grade mitral regurgitation, as diagnosed by echocardiography. In consideration of the preoperative and intraoperative findings, and the patient's low age, a mitral valve repair with removal of the leaflet vegetations and a ring annuloplasty were performed.

Mitral valve repair for degenerative mitral valve regurgitation.

In industrialized countries, the most common etiology of mitral regurgitation (MR) is degenerative mitral valve (MV) disease. The natural history of severe degenerative MR is poor. However, its appropriate and timely correction is associated with a life expectancy similar to that of the normal population. Surgical MV repair is the gold-standard treatment. This review will focus on the most recent evidence with a specific emphasis on surgical indications, timing of treatment, contemporary surgical techniques, Heart Teams, and Centers of Excellence.

Prolapse of the posterior leaflet: resect or respect.

Prolapse of the posterior leaflet (PPL) is the most frequent dysfunction of the mitral valve in the western world. Quadrangular resection, first proposed by Alain Carpentier, has progressed to become the gold standard modality to repair posterior leaflet prolapse. Although this "resection technique" is safe, reproducible, and offers favorable long term results, it presents major drawbacks. Firstly, it leads to a reduced surface of coaptation, the ultimate goal of mitral valve repair; secondly, it does not respect the anatomy of the mitral valve; thirdly, it leads to a deformation of the base of the ventricle; and finally, degenerative disease of the mitral valve is a spectrum of lesions depending on the amount of excess tissue, and hence, a one technique-fits-all strategy cannot meet the absolute necessity to repair all mitral valve patients with PPL. Therefore, new approaches which have been proposed place greater emphasis on respecting, rather than only resecting, the leaflet tissue in order to avoid the drawbacks of the "resection" approach. The use of artificial chordae to correct the leaflet prolapse restores the normal anatomy and physiology of the mitral valve, thus producing an optimal surface of coaptation. However, this approach is limited by anatomical variances. As a community, we should expand our vision and define a clear and helpful strategy for PPL: to obtain a high, smooth and regular surface of coaptation located in the inflow of the left ventricle. To achieve this goal, it is necessary to have a high level of respect for the leaflet tissue in order to obtain the best surface of coaptation. Nonetheless, a limited resection may be needed to remodel the posterior leaflet, so that it will be smooth and regular.

Totally endoscopic set-up for mitral valve repair.

Minimally invasive mitral surgery is increasingly recognized as routine. We describe here the financially economical set-up for totally endoscopic surgery, which also represents currently the smallest surgical access, limited only by prosthesis and retractor size. This allows the full range of repairs to be performed. Cannulation for cardiopulmonary bypass is performed via the groin. A cosmetic, periareolar (in males) or inframammary fold (in females) incision is made and the chest entered on bypass. An aortic cross-clamp and crystalloid cardioplegia are used via the aortic root prior to atriotomy and surgical repair. This method gives the highest level of cosmesis available and minimal discomfort, without compromising on the extremely good published results.

Rate of repair in minimally invasive mitral valve surgery.

BACKGROUND: Valve repair has been shown to be the method of choice in the treatment of patients with severe mitral valve regurgitation. Minimally invasive surgery has raised skepticism regarding the rate of repair especially for supposedly complex lesions, when anterior leaflet involvement or bileaflet prolapse is present. We sought to review our experience of all our patients presenting with degenerative mitral valve regurgitation and operated on minimally invasively. METHOD: From September 2006 to December 2012, 842 patients (mean age 56.12±11.62 years old) with degenerative mitral valve regurgitation and anterior leaflet (n=82, 9.7%), posterior leaflet (n=688, 81.7%) and bileaflet (n=72, 8.6%) prolapses were operated on using a minimally invasive approach. RESULTS: 836 patients had a valve repair (99.3%) and received a concomitant ring annuloplasty (mean size, 33.7; range, 28-40). Six patients (0.7%) underwent valve replacement. Two patients had a re-repair due to MR progression or infective endocarditis. Thirty-day mortality was 0.2% (two patients). There were 60 major adverse events (MAE) (7.1%). CONCLUSIONS: A minimally invasive approach allows repair of almost all degenerative valves with good short-term outcomes in a tertiary referral center, when using proven and efficient surgical techniques.

Toward a new paradigm for the reconstruction of posterior leaflet prolapse: midterm results of the "respect rather than resect" approach.

BACKGROUND: The aim of mitral valve reconstruction is restoration of good coaptation surface. Resection of the prolapsed area has been the accepted technique to repair prolapse of the posterior leaflet (PPL). However, as leaflet tissue is the basic component of coaptation surface, the logical corrective approach was thought to be the transformation of the posterior leaflet into a smooth vertical buttress without resection, the "respect rather than resect" approach. METHODS: Between 1994 and 2004, 225 patients underwent a PPL repair for severe mitral regurgitation with the respect rather than resect approach, in which the prolapse was corrected with artificial chordae. In 193 patients, the prolapse was limited to the posterior leaflet; in the remaining 32 patients, both leaflets were involved. All patients received ring annuloplasty. Associated procedures included myocardial revascularization (21 patients) and tricuspid repair (19 patients). Patient demographics were as follows: mean age, 60.7 +/- 12.9 years; male, 150 (67%); asymptomatic, 102 (45%). RESULTS: Three patients died postoperatively (1.3%). Survival at 10 years (88% +/- 6%) was similar to expected survival rate (97% +/- 2% for asymptomatic patients and 82% +/- 10% for symptomatic patients (p < 0.005)). Ten patients were reoperated on, for a freedom from reoperation rate of 93% +/- 3% at 10 years. At echocardiographic follow-up, 172 patients of 195 (88%) showed mitral regurgitation of 1 or less; and 195 of 203 patients (96%) were in New York Heart Association functional class I or II. CONCLUSIONS: The respect rather than resect approach is safe, effective, and durable, and increases technical repair possibilities. Surgical strategy focuses on restoration of surface coaptation instead of location and extent of leaflet resection.