The Evolution of Transcatheter Therapies for Mitral Valve Disease: From Mitral Valvuloplasty to Transcatheter Mitral Valve Replacement.

The prevalence of mitral valve disease has evolved over the past 5 decades from primarily a disease of rheumatic origin to a disease affecting the aging population that encompasses a range of phenotypes from rheumatic mitral stenosis, degenerative mitral regurgitation, and degenerative mitral valve calcification to secondary mitral regurgitation. A reflection on the history of therapy for mitral valve disease is an expedition that follows the birth and development of structural heart intervention from the first percutaneous balloon mitral valvuloplasty to innovative technologies for transcatheter mitral valve repair and replacement. This review will lead you along this journey, pause to acknowledge the feats accomplished, and reflect on the road that lies ahead.

Use of Mobile-Based Application for Collection of Patient-Reported Outcomes in Cardiac Surgery.

OBJECTIVE: Application-based (app) technology has been studied for patient engagement and collecting patient-reported outcomes (PROs) in several surgical specialties with limited research in cardiac surgery. The aim of study was to determine the effectiveness of app-based technology for collecting PROs, improving the patient experience, and reducing health services utilization in a cardiac surgery center. METHODS: Patients accessed an interactive app via smartphones. Patients were guided from 4 weeks preoperative to 4 weeks postoperative via reminders, tasks, PRO surveys, and evidence-based education. In the postoperative period, patients were engaged with daily health surveys to track warning signs and recovery milestones. Based on the patient's signs and symptoms, the app escalated lower risk issues to self-care education or higher risk issues to the care team (e.g., phone call to a nurse). RESULTS: Sixty-six percent of patients (730 of 1,108) activated their app account. Two hundred seventy-seven patients completed an end-of-program feedback survey, with 94% of patients recommending the app and 98% of patients finding the app was helpful in recovery. Patients also reported using the app to avoid unnecessary health services utilization, with 45% of patients using the app to avoid at least 1 phone call and 28% of patients using the app to avoid at least 1 hospital visit. CONCLUSIONS: App-based technology for patient engagement is an effective modality to enhance the patient experience, better understand the trajectory of recovery, and reduce unnecessary health services utilization in cardiac surgery.

Optimizing Timing of Valve Intervention in Patients With Asymptomatic Severe Valvular Heart Disease.

The management of valvular heart disease has changed dramatically over the past decade with advances in cardiac imaging, the use of novel biomarkers, and the development of transcatheter valve repair and replacement technology. International society guidelines have kept pace to provide recommendations for diagnosis, follow-up, and timing of intervention. The most challenging patient cohort for clinicians are patients with asymptomatic severe disease in whom the optimal timing of intervention can be ill-defined. It is a fine balance between the risks of early intervention on asymptomatic patients and improving patient outcomes by preventing long-term cardiac complications. The key in optimal patient management is gathering the necessary information on patient risk and combining that with the risk, efficacy, and durability of valve interventions to arrive at the appropriate timing for intervention. This group of patients will be the focus of this review as we delve into the natural history, recommended follow-up, and indications for intervention in patients with degenerative aortic and mitral valve disease.

Sudden Tamponade From Vein Graft Side Branch Avulsion on Removal of Temporary Pacemaker Wires.

Temporary epicardial pacing wires are universally used in cardiac surgery and are associated with very low morbidity and mortality. Although rare, serious complications can occur with pacing wires. We present a case of avulsion of a saphenous vein graft side branch caused by removal of pacing wires and leading to pericardial tamponade. Our case favors the use of silk ties rather than hemoclips for occlusion of saphenous vein side branches and illustrates the importance of the location of pacing wires relative to the grafts at the time of coronary artery bypass surgery.

Initial clinical experience with VersaCross transseptal system for transcatheter mitral valve repair.

OBJECTIVES: The aim of this study is to describe the initial experience with versacross transseptal (TS) system for transseptal puncture for the transcatheter mitral valve repair using the MitraClip device. BACKGROUND: Transeptal puncture is a key step in transcatheter mitral valve repair (MVR) and the use of the VersaCross system comprised of a sheath, a dilator and a radiofrequency wire has not been previously described. METHODS: Prospective single center study of consecutive patients undergoing transcatheter mitral valve repair with the MitraClip device were included. Targeted TS puncture was performed under transesophageal echocardiographic (TEE) guidance. Baseline demographics, procedural characteristics, and major adverse procedural events were collected. RESULTS: Twenty-five consecutive patients underwent transseptal puncture using the VersaCross TS system. Transseptal puncture was successful in 100% of patients. The mean time for TS puncture was 3 3 ± 1.6 min with no major adverse procedural events. The mean time from insertion of the VersaCross system to insertion of the MitraClip guide catheter was 3.8 ± 3.0 minutes. CONCLUSION: The VersaCross TS system was successful in all patients for MitraClip procedure with no adverse procedural events and may be associated with increased procedural efficiency.

The Department of Surgery of the Université de Montréal, 70th anniversary.

SUMMARY: The Department of Surgery of the Université de Montréal was officially chartered in 1961, but the structure had been in place since since 1951. The department grew as a fusion of hospital-based surgery training programs from the largest French-speaking hospitals in Montreal. Currently 448 professors (135 women and 313 men) teach in the department. The research activity, both clinical and applied, is in strong progression. The Department of Surgery is the largest French and bilingual training centre in Canada and North America. In 2021 the department will celebrate its 70th anniversary. As members, we should be proud of the work achieved by our predecessors and by the current rank of professors, teachers and researchers. The department strives to promote the essential role of and highlight the rewards and benefits of academic surgery.

Venoarterial Extracorporeal Membrane Oxygenation Support for Severe Pericardial Decompression Syndrome: A Case Report.

OBJECTIVES: We report a case of a man with tamponade decompression syndrome following pericardial drainage. DATA SOURCES: ICU - Montreal Heart Institute. STUDY SELECTION: Case report. DATA EXTRACTION: Clinical and surgical records. DATA SYNTHESIS: None. CONCLUSIONS: Our case adds further concerns in supporting a patient with tamponade decompression syndrome, including mechanical circulatory support, due to the reversible nature of this condition.

Myocardial Protection in Minimally Invasive Mitral Valve Surgery: Retrograde Cardioplegia Alone Using Endovascular Coronary Sinus Catheter Compared With Combined Antegrade and Retrograde Cardioplegia.

OBJECTIVE: To compare myocardial protection with retrograde cardioplegia alone with antegrade and retrograde cardioplegia in minimally invasive mitral valve surgery (MIMS). DESIGN: Retrospective study. SETTING: Tertiary care university hospital. PARTICIPANTS: The authors studied 97 MIMS patients using retrograde cardioplegia alone and 118 MIMS patients using antegrade and retrograde cardioplegia. INTERVENTIONS: The data from patients admitted for MIMS using retrograde cardioplegia (MIMS retro) between 2009 to 2012 were compared with the data from patients undergoing MIMS with antegrade and retrograde cardioplegia (MIMS ante-retro) between 2006 and 2010 (control group). Cardioplegia in the MIMS retro group was delivered solely through an endovascular coronary sinus (CS) catheter positioned under echographic and fluoroscopic guidance. Antegrade and retrograde cardioplegia was used in the MIMS ante-retro group. Data regarding myocardial infarction (MI; creatine kinase Mb, troponin T, electrocardiogram), myocardial function, and hemodynamic stability were collected for comparison. MEASUREMENTS AND MAIN RESULTS: Adequate cardioplegia administration (CS pressure >30 mmHg and asystole) was attained in 74.2% of the patients with retrograde cardioplegia alone. In 23.7% of the patients, the addition of an antegrade cardioplegia was necessary. No difference was observed in the incidence of MI (0 MIMS retro v 1 for MIMS ante-retro, p = 0.3623), difficult separation from cardiopulmonary bypass, and postoperative malignant arrhythmia. No difference was found for maximal creatine kinase Mb (39.1 [28.0-49.1] v 37.9 [28.6-50.9]; p = 0.8299) and for maximal troponin T levels (0.39 [0.27-0.70] v 0.47 [0.32-0.79]; p = 0.1231) for MIMS retro and MIMS ante-retro, respectively. However, lactate levels in the MIMS retro group were significantly lower than in the MIMS ante-retro group (2.1 [1.4-3.05] v 2.4 [1.8-3.3], respectively; p = 0.0453). No difference was observed in duration of intensive care unit stay and death. MIMS retro patients had a shorter hospital stay (7.0 [6.0-8.0] v 8.0 [7.0-9.0] days; p = 0.0003). CONCLUSION: Retrograde cardioplegia administration alone provided comparable myocardial protection to antegrade and retrograde cardioplegia during MIMS, but was not sufficient to achieve asystole in one-fifth of patients.

Mini Right Anterior Thoracotomy Approach Versus Sternotomy for Resection of Intracardiac Myxoma.

OBJECTIVE: The standard approach in treating cardiac myxoma is the median full sternotomy. After recent advances in surgical techniques, the mini right anterior thoracotomy has emerged as an alternative method. METHODS: We performed a retrospective study to compare the clinical outcomes of the mini right anterior thoracotomy approach with those of the sternotomy approach for resection of cardiac myxoma at the Montreal Heart Institute. There were 20 patients treated using a mini right anterior thoracotomy (4-5 cm) and 23 patients were treated using a median sternotomy. RESULTS: No early mortalities were found in either group. Although the cardiopulmonary bypass time and aorta cross-clamp time were not significantly different between the two groups (64.3 mn ± 18 and 37.2 mn ± 15 vs 54.3 mn ± 25 and 37.20 mn ± 2), preoperative blood loss (106 mn ± 95 vs 338 mn ± 270) was significantly less in the mini right anterior thoracotomy group. The intensive care unit and hospital stay (1.65 days ± 1.2 and 5.70 days ± 3) were shorter with the mini right anterior thoracotomy approach. CONCLUSIONS: A minimally invasive surgery through mini right anterior thoracotomy is a good alternative technique for treating cardiac myxoma. Despite the small size of the experience, there is a clear diminution in preoperative blood loss and an interesting trend toward a shorter intensive care unit and hospital stay.

Myocardial Protection in Mitral Valve Surgery: Comparison Between Minimally Invasive Approach and Standard Sternotomy.

OBJECTIVE: To compare antegrade and retrograde cardioplegia administration in minimally invasive mitral valve surgery (MIMS) and open mitral valve surgery (OMS) for myocardial protection. DESIGN: Retrospective study. SETTING: Tertiary care university hospital. PARTICIPANTS: The study comprised 118 patients undergoing MIMS and 118 patients undergoing OMS. INTERVENTIONS: The data of patients admitted for MIMS from 2006 to 2010 were reviewed. Patients undergoing isolated elective OMS from 2004 to 2006 were used as a control group. Cardioplegia in the MIMS group was delivered via the distal port of the endoaortic clamp and an endovascular coronary sinus catheter positioned using echographic and fluoroscopic guidance. Antegrade and retrograde cardioplegia were used in OMS. Data regarding myocardial infarction (MI) (creatine kinase [CK]-MB, troponin T, electrocardiography); myocardial function; and hemodynamic stability were collected. MEASUREMENTS AND MAIN RESULTS: There was no difference in the perioperative MI incidence between both groups (1 in each group, p = 0.96). No statistically significant difference was found for maximal CK-MB (35.9 µg/L [25.1-50.1] v 37.9 µg/L [28.6-50.9]; p = 0.31) or the number of patients with CK-MB levels >50 µg/L (29 v 33; p = 0.55) or CK-MB >100 µg/L (3 v 4; p = 0.70) between the OMS and MIMS groups. However, maximum troponin T levels in the MIMS group were significantly lower (0.47 µg/L [0.32-0.79] v 0.65 µg/L [0.45-0.94]; p = 0.0007). No difference in the incidence of difficult weaning from bypass and intra-aortic balloon pump use between the MIMS and OMS groups was found. CONCLUSIONS: Antegrade and retrograde cardioplegia administration during MIMS and OMS provided comparable myocardial protection.

Surgery Versus Transcatheter Interventions for Significant Paravalvular Prosthetic Leaks.

OBJECTIVES: This study sought to assess the relative merit of surgical correction (SC) versus transcatheter reduction on long-term outcomes in patients with significant paravalvular leak (PVL) refractory to medical therapy. BACKGROUND: PVL is the most frequent dysfunction following prosthetic valve replacement. Although repeat surgery is the gold standard, transcatheter reduction (TR) of PVL has been associated with reduced mortality. METHODS: From 1994 to 2014, 231 patients underwent SC (n = 151) or TR (n = 80) PVL correction. Propensity matching and Cox proportional hazards regression models were used to assess the effect of either intervention on long-term rates of all-cause death or hospitalization for heart failure. Survival after TR and SC were further compared with the survival in a matched general population and to matched patients undergoing their first surgical valve replacement. RESULTS: Over a median follow-up of 3.5 years, SC was associated with an important reduction in all-cause death or hospitalization for heart failure compared with TR (hazard ratio: 0.28; 95% confidence interval: 0.18 to 0.44; p < 0.001). There was a trend towards reduced all-cause death following SC versus TR (hazard ratio: 0.61; 95% confidence interval: 0.37 to 1.02; p = 0.06). Neither intervention normalized survival when compared with a general population or patients undergoing their first surgical valve replacement. CONCLUSIONS: In patients with significant prosthetic PVL, surgery is associated with better long-term outcomes compared with transcatheter intervention, but results in important perioperative mortality and morbidity. Future studies are needed in the face of increasing implementation of transcatheter PVL interventions across the world.

Experience with the SynCardia total artificial heart in a Canadian centre.

BACKGROUND: The SynCardia total artificial heart (TAH) provides complete circulatory support by replacing both native ventricles. Accepted indications include bridge to transplantation and destination therapy. We review our experience with TAH implantation during a period when axial flow pump became available. METHODS: We retrospectively analyzed the demographics, clinical characteristics and survival of all patients receiving the TAH. RESULTS: From September 2004 to November 2016, 13 patients (12 men, mean age 45 ± 13 yr) received the TAH for refractory cardiogenic shock secondary to idiopathic (56%) or ischemic (17%) cardiomyopathy and to other various causes (33%). Before implantation, mean ejection fraction was 14% ± 4%, 7 (54%) patients had previous cardiac surgery, 4 (31%) were on mechanical ventilation, and 3 (23%) patients were on dialysis. The mean duration of TAH support was 46 ± 40 days. Three (23%) patients died while on support after a mean of 15 days. Actuarial survival on support was 77% ± 12% at 30 days after implantation. Complications on support included stroke (n = 1, 8%), acute respiratory distress syndrome requiring prolonged intubation (n = 5, 38%) and acute renal failure requiring temporary dialysis (n = 5, 38%). Ten (77%) patients survived to be transplanted after a mean of 52 ± 42 days of support. Actuarial survival rates after transplant were 67% ± 16% at 1 month and 56% ± 17% at 1 year after transplantation. CONCLUSION: The TAH provides an alternative with low incidence of neurologic events in extremely fragile and complex patients waiting for heart transplantation. Complex and unusual anatomic conditions explained the current use of TAH.

CONTEXTE: Le cœur artificiel total (CAT) SynCardia offre un soutien circulatoire complet en remplaçant les 2 ventricules naturels. Parmi ses indications acceptées, mentionnons la transition pré-greffe et l'assistance permanente. Nous passons ici en revue notre expérience en matière d'implantation de CAT à partir de l'avènement des pompes à flux axial. MÉTHODES: Nous avons analysé de manière rétrospective les caractéristiques démographiques et cliniques et la survie de tous les patients ayant reçu un CAT. RÉSULTATS: De septembre 2004 à novembre 2016, 13 patients (12 hommes, âge moyen 45 ± 13 ans) ont reçu le CAT pour un choc cardiogénique réfractaire dû à la cardiomyopathie idiopathique (50 %) ou ischémique (17 %) ou à d'autres causes (33 %). Avant l'implantation, la fraction d'éjection était en moyenne de 14 % ± 4 %, 7 patients (54 %) avaient déjà subi une chirurgie cardiaque, 4 (31 %) étaient sous ventilation mécanique et 3 (23 %) étaient dialysés. La durée moyenne du soutien par CAT a été de 46 ± 40 jours. Trois patients (23 %) sont décédés malgré l'implantation du dispositif après une moyenne d'utilisation de 15 jours. La survie actuarielle pendant l'utilisation du dispositif a été de 77 % ± 12 % 30 jours suivant l'implantation. Les complications ont inclus : accident vasculaire cérébral (n = 1, 8 %), syndrome de détresse respiratoire aigüe nécessitant une intubation prolongée (n = 5, 38 %) et insuffisance rénale aigüe nécessitant une dialyse temporaire (n = 5, 38 %). Dix patients (77 %) ont survécu jusqu'à leur greffe après une moyenne d'utilisation de 52 ± 42 jours. Les taux de survie actuarielle après la greffe ont été de 67 % ± 16 % après 1 mois et de 56 % ± 17 % après 1 an suivant la greffe. CONCLUSION: Le CAT est une solution de rechange qui s'accompagne d'une incidence faible de complications neurologiques chez des patients à l'état extrêmement fragile et complexe en attente d'une greffe cardiaque. Des complications anatomiques inhabituelles ont expliqué l'utilisation du CAT.

Changes in patient characteristics following cardiac transplantation: the Montreal Heart Institute experience.

BACKGROUND: Heart transplantation is no longer considered an experimental operation, but rather a standard treatment; nevertheless the context has changed substantially in recent years owing to donor shortage. The aim of this study was to review the heart transplant experience focusing on very long-term survival (≥ 20 years) and to compare the initial results with the current era. METHODS: From April 1983 through April 1995, 156 consecutive patients underwent heart transplantation. Patients who survived 20 years or longer (group 1) were compared with patients who died within 20 years after surgery (group 2). To compare patient characteristics with the current era, we evaluated our recent 5-year experience (group 3; patients who underwent transplantation between 2010 and 2015), focusing on differences in terms of donor and recipient characteristics. RESULTS: Group 1 (n = 46, 30%) included younger patients (38 ± 11 v. 48 ± 8 yr, p = 0.001), a higher proportion of female recipients (28% v. 8%, p = 0.001) and a lower prevalence of ischemic heart disease (42% v. 65%, p = 0.001) than group 2 (n = 110, 70%). Patients in group 3 (n = 54) were older (52 ± 12 v. 38 ± 11 yr, p = 0.001), sicker (rate of hospital admission at transplantation 48% v. 20%, p = 0.001) and transplanted with organs from older donors (42 ± 15 v. 29 ± 11 yr, p = 0.001) than those in group 1. CONCLUSION: Very long-term survival ( ≥ 20 yr) was observed in 30% of patients transplanted during the first decade of our experience. This outcome will be difficult to duplicate in the current era considering our present population of older and sicker patients transplanted with organs from older donors.

CONTEXTE: De nos jours, la transplantation cardiaque n'est plus considérée comme une intervention expérimentale, mais bien comme une opération standard; mais le contexte a substantiellement changé ces dernières années en raison d'une pénurie de donneurs. Cette étude avait pour but de faire le point sur la situation de la greffe cardiaque, et plus particulièrement sur la survie à très long terme (≥ 20 ans), et de la comparer aux résultats initiaux. MÉTHODES: Entre avril 1983 et avril 1995, 156 patients consécutifs ont subi une greffe cardiaque. Les patients qui ont survécu 20 ans ou plus (groupe 1) ont été comparés aux patients décédés moins de 20 ans après l'intervention (groupe 2). Pour comparer les caractéristiques des premiers patients à celles des cas plus récents, nous avons fait un bilan des 5 années allant de 2010 à 2015 (groupe 3), en portant attention aux différences quant aux caractéristiques des donneurs et des receveurs. RÉSULTATS: Le groupe 1 (n = 46, 30 %) incluait des patients plus jeunes (38 ± 11 ans c. 48 ± 8 ans, p = 0,001), une proportion plus élevée de femmes (28 % c. 8 %, p = 0,001) et la prévalence de maladie cardiaque ischémique y était moindre (42 % c. 65 %, p = 0,001) comparativement au groupe 2 (n = 110, 70 %). Les patients du groupe 3 (n = 54) étaient plus âgés (52 ± 12 ans c. 38 ± 11 ans, p = 0,001), plus malades (taux d'hospitalisation au moment de la transplantation 48 % c. 20 %, p = 0,001) et ont reçu le cœur de donneurs plus âgés (42 ± 15 ans c. 29 ± 11 ans, p = 0,001) que ceux du groupe 1. CONCLUSION: Une survie à très long terme (≥ 20 ans) a été observée chez 30 % des patients ayant reçu leur greffe au cours de la première décennie de notre expérience. Ce résultat sera difficile à reproduire de nos jours étant donné que notre population actuelle est constituée de receveurs plus âgés et plus malades, qui reçoivent le cœur de donneurs plus âgés.

Mycobacterium chimaera Infection After Cardiac Surgery: First Canadian Outbreak.

Recently reported in Europe and United States, disseminated Mycobacterium chimaera infection is a novel clinical entity linked to point contamination of Stockert 3T heater-cooler units used for cardiopulmonary bypass. We present here the first two cases in Canada. Both patients presented with nonspecific extracardiac symptoms 1 year after undergoing minimally invasive mitral surgical repair. Before the right diagnosis was established, the patients were initially treated with prednisone for suspected sarcoidosis. One patient is currently improving, and the other needed mitral valve repair despite aggressive treatment. Because of the nonspecific mode and timing of presentation, a high index of suspicion is necessary for the diagnosis of M. chimaera infection.

Reexamining the Role of Surgical Aortic Valve Replacement After Mediastinal Radiation Therapy.

BACKGROUND: The risk of aortic valve replacement (AVR) for patients after mediastinal radiation therapy (MRT) remains unaccounted for in traditional risk scores. The aim of this study was to examine perioperative and midterm outcomes in patients undergoing AVR after MRT in the current era. METHODS: From 2000 to 2016, 49 consecutive patients previously exposed to MRT underwent AVR with or without concomitant procedures at a single center. Patients were divided into two groups: isolated AVR (n = 18) and AVR with concomitant procedures (n = 31). The logistic European System for Cardiac Operative Risk Evaluation II mean score was 2.8% ± 3.4% and The Society of Thoracic Surgeons mean score was 1.7% ± 1.5%. Median follow-up was 6.6 years and was 90% complete within 12 months of study closure. RESULTS: Overall inhospital mortality was 10% (0% in the isolated group versus 16% in the concomitant group; p = 0.14). A total of 21 patients (47%) died at follow-up. Mean interval to death was 2.0 ± 1.1 years from surgery in the isolated group versus 1.4 ± 1.6 years in the concomitant group (p = 0.18). Actuarial survival was 93% ± 6%, 73% ± 11%, and 65% ± 13%, at 1, 3, and 5 years, respectively, in the isolated group versus 74% ± 8%, 44% ± 11%, and 37% ± 11% in the concomitant group (p = 0.03). CONCLUSIONS: Isolated AVR can be performed safely in patients with MRT-induced disease. In contrast, AVR with concomitant procedures is associated with high mortality, which is vastly underestimated using traditional risk scores. In both groups, survival at 5 years is markedly impaired.

Del Nido cardioplegia in the setting of minimally invasive aortic valve surgery.

The purpose of this study is to report our experience with del Nido cardioplegia (DNC) in the setting of minimally invasive aortic valve surgery. Forty-six consecutive patients underwent minimally invasive aortic valve replacement (AVR) through a "J" ministernotomy: twenty-five patients received the DNC (Group 1) and 21 patients received standard blood cardioplegia (SBC) (Group 2). The rate of ventricular fibrillation at unclamping was significantly lower in the DNC group (12% vs 52%, p=0.004), as well as postoperative creatinine kinase-MB (CK-MB) values (11.4±5.2 vs 17.7±6.9 µg/L, p=0.004). There were no deaths, myocardial infarctions or major complications in either group. Less postoperative use of intravenous insulin (28% vs 81%, p<0.001) was registered in the DNC group. In conclusion, the DNC is easy to use and safe during minimally invasive AVR, providing a myocardial protection at least equivalent to our SBC, improved surgical efficiency, minimal cost and less blood glucose perturbations.

Repair of Anterior Mitral Leaflet Prolapse: Comparison of Mid-Term Outcomes with Chordal Transposition and Chordal Replacement Techniques.

BACKGROUND: The repair of anterior mitral leaflet prolapse is known to be challenging. Hence, the study aim was to compare the mid-term results of anterior leaflet prolapse (ALP) using chordal transposition with results obtained using chordal replacement with expanded polytetrafluoroethylene (ePTFE) sutures. METHODS: Between 1999 and 2012, a total of 96 consecutive patients (mean age 62 years) with ALP underwent mitral valve repair at the authors' institution. Surgery involved either chordal transposition from the posterior to the anterior leaflet (n = 67), or chordal replacement using ePTFE sutures (n = 29). Clinical, operative and follow up data were recorded prospectively for each patient. The follow up was 100% complete (mean 3.4 years; range 0 to 12.9 years). RESULTS: Mitral valve repair was accomplished in all patients, with no operative mortality. The durations of cardiopulmonary bypass and aortic cross-clamp were significantly longer in the chordal replacement group. Actuarial overall survival at one, five and 10 years was 95 ± 3%, 87 ± 5% and 82 ± 7% versus 89 ± 6%, 89 ± 6% and 89 ± 6% in the chordal transposition and chordal replacement groups, respectively (p = 0.84). Freedom from reoperation in the two groups at five years was 95 ± 3% and 91 ± 7%, respectively (p = 0.24). The recurrence of moderate or severe mitral regurgitation (MR) (grade ≤2+) and of severe (grade ≤3+) MR was significantly higher in patients who underwent chordal replacement compared to chordal transposition (p = 0.04 and p = 0.01, respectively). CONCLUSIONS: Provided that chordal quality is preserved, chordal transposition is easier and quicker to achieve for ALP repair, and is also durable in the mid term. Chordal replacement offers a satisfying durability even if the recurrence of severe MR appears to be higher. Preferably, both surgical techniques should be mastered to allow valve repair when anatomic conditions prevent chordal transposition.