- Academic Editor
Background: Mitral valve repair (MVr) is an effective treatment for degenerative mitral regurgitation (DMR).And the outcomes and repair rates for posterior leaflet prolapse (PLP), anterior leaflet prolapse (ALP), and bileaflet prolapse (BLP) vary. This study aimed to compare the outcomes of mitral valve
repair for patients with PLP, ALP, and BLP. Methods: From 2010
to 2019, 1192 patients with degenerative mitral valve regurgitation underwent
surgery at our hospital. And 1069 patients were identified. The average age of
all patients was (54.74
Degenerative mitral valve regurgitation is the one of the most common valve diseases in the world [1]. It is generally accepted that mitral valve repair (MVr) is a more preferred choice than mitral valve replacement (MVR) for degenerative mitral regurgitation (DMR) [2, 3], the outcomes and repair rates for posterior leaflet prolapse (PLP), anterior leaflet prolapse (ALP), and bileaflet prolapse (BLP) vary.
Although ALP and BLP repairs are more challenging than PLP repair, studies have demonstrated that PLP repair is more durable than ALP and BLP repairs are [4], prompting some surgeons to favor MVR for ALP and BLP. Compared with developed Western countries, institutions in China adopted MVr considerably later. In addition, comparisons of outcomes between ALP, PLP, and BLP repair are rare. As the second-largest cardiac surgery center in China, we have gained considerable experience regarding degenerative mitral repair. In this study, we retrospectively analyzed patients with degenerative mitral valve regurgitation and compared the outcomes of mitral valve repair for patients with PLP, ALP, and BLP.
From 2010 to 2019, 1192 patients with degenerative mitral valve regurgitation underwent surgery at our hospital. Patients who were younger than 18 years old, concomitant with congenital heart disease (CHD), and had heart surgery previously were excluded. And 1069 patients were identified. Patients were divided into PLP, ALP, and BLP groups according to their mitral valve pathology.
All procedures were performed through a median sternotomy. Aorta and superior and inferior vena cava intubations were used to establish cardiopulmonary bypass. The mitral valve was exposed through a right atrium, atrial septal, or atrial sulcus incision. Before surgery, TEE was performed conventionally to further explore the structure of MV, help us better establish the surgical plans.
PLP was corrected through quadrangular or triangular resection and involved the use of the sliding technique if further resection was needed. Due to the importance of the recent “respect rather than resect” principle, the leaflet folding and polytetrafluoroethylene chordae were also adapted, especially for patients with isolated P2 prolapse. For commissural prolapse, the commissural closure or folding was used.
ALP repair is considered more challenging than PLP repair. Therefore, for patients with ALP, polytetrafluoroethylene chordae, commissural closure and triangular resection were adopted. Additionally, the size of annuloplasty ring or band was according to the surface area of the anterior leaflet.
Transoesophageal echocardiography was routinely performed to evaluate the quality of the repair. If there were residual moderate MR, it would be re-repaired.
Othe procefures were also performed as required.
The patients were followed up at 3, 6, and 12 months, and then annually. The
outcomes include the long term survival, recurrent mitral valve regurgitation and
mitral valve reoperation. The degree of regurgitation was classified as mild
(effective regurgitate orifice area (EROA)
Data are presented as mean
Cox’s proportional hazard regression model was used to evaluate the effects of multiple potential factors on long-term survival. Kaplan–Meier analysis was used to assess the differences in survival among the groups. The log-rank test determined statistical significance among the risk categories for all Kaplan–Meier analyses. Data analysis was performed using SPSS version 22 (SPSS, Inc. Chicago, IL, USA) and R 3.6.1 using the cmprsk package (R Foundation for Statistical Computing, 169 Vienna, Austria).
In total, 1069 patients were identified in this study, among whom 273 (25.5%) had ALP, 148 (13.8%) had BLP, and 648 (60.6%) had PLP. A total of 90 patients underwent MVR, among whom 27 had ALP, 30 had PLP, and 33 had BLP. The total repair rate was nearly 92%, with 91% for ALP, 95% for PLP, and 82% for BLP. Patients with ALP or BLP had a higher probability of repair failure than patients with PLP.
60 patients were considered to have Barlow’s disease. Most patients with ALP
(65.7%) were female, while males constituted the majority of patients with ALP
(35.5%) and BLP (35.1%). Patients with PLP were the oldest (56.30
Variables | PLP (n = 648) | ALP (n = 273) | BLP (n = 148) | p-value | |
Female gender | 426 (65.7%) | 97 (35.5%) | 52 (35.1%) | 0.927 | |
Age | 56.30 |
53.33 |
50.46 |
||
BMI | 24.97 |
24.23 |
24.22 |
0.002 | |
NYHA class | 0.162 | ||||
I | 12 (2%) | 9 (3.3%) | 8 (5.4%) | ||
II | 434 (67%) | 175 (64.1%) | 103 (69.6%) | ||
III | 189 (29%) | 83 (30.4%) | 33 (22.3%) | ||
VI | 13 (2%) | 6 (2%) | 4 (3%) | ||
Hypertension | 282 (44%) | 90 (33%) | 46 (31%) | 0.001 | |
AF | 192 (30%) | 108 (40%) | 44 (30%) | 0.010 | |
CAD | 67 (10%) | 23 (8%) | 12 (8.1) | 0.542 | |
DM | 54 (8%) | 12 (4%) | 9 (6%) | 0.091 | |
CVD | 26 (4%) | 12 (4%) | 4 (23) | 0.684 | |
Echocardiographic data | |||||
LAD (mm) | 46.50 |
48.34 |
46.80 (10.71) | 0.026 | |
LVEDD (mm) | 56.31 |
57.56 |
57.57 |
0.018 | |
LVESD (mm) | 36.38 |
37.83 |
37.18 |
0.003 | |
EF (%) | 63.14 |
62.21 |
63.17 |
0.141 | |
Peak E wave velocity | 124.85 (35.65) | 120.58 (37.37) | 124.66 (36.85) | 0.443 | |
More than moderate TR | 164 (25%) | 86 (32%) | 27 (18%) | 0.011 | |
PHT | 308 (47%) | 145 (53%) | 89 (60%) | 0.130 | |
Mild | 213 (33%) | 91 (33%) | 50 (34%) | ||
Moderate | 68 (10%) | 27 (10%) | 9 (6%) | ||
Severe | 27 (4%) | 10 (4%) | 0 (0%) |
PLP, posterior leaflet prolapse; ALP, anterior leaflet prolapse; BLP, bileaflet prolapse; BMI, body mass index; NYHA, New York Heart Association; AF, atrial fibrillation; CAD, coronary heart disease; DM, diabetes mellitus; CVD, cerebral vascular disease; LAD, left atrial diameter; LVEDD, left ventricular end-diastolic diameter; LVESD, left ventricular end-systolic diameter; EF, ejection fraction; TR, tricuspid regurgitation; PHT, pulmonary hypertension.
The Maze procedure was more common for ALP repair. BLP repair had longer cardiopulmonary bypass (CPB) and
aortic cross-clamp durations than PLP and ALP repairs (p
Variables | PLP (n = 648) | ALP (n = 273) | BLP (n = 148) | p-value |
Other procedures | ||||
TVP | 424 (65%) | 188 (69%) | 98 (66%) | 0.601 |
Maze procedure | 181 (28%) | 101 (37%) | 40 (27%) | 0.016 |
AVR | 37 (6%) | 19 (7%) | 8 (5%) | 0.728 |
CABG | 46 (7%) | 17 (6%) | 8 (5%) | 0.719 |
CPB time | 104.90 |
112.37 |
124.99 |
|
Cross-clamp time | 72.96 |
81.67 |
92.34 |
PLP, posterior leaflet prolapse; ALP, anterior leaflet prolapse; BLP, bileaflet prolapse; TVP, tricuspid valvuloplasty; AVR, aortic valve replacement; CABG, coronary artery bypass grafting; CPB, cardiopulmonary bypass.
The surgical techniques were shown in Table 3 detail. The average size of the annuloplasty ring was 32 mm. The Carpentier-Edwards Physio I/II Semirigid Annuloplasty Rings were most frequently used (n = 874). The Sorin Memo 3D Semirigid Annuloplasty Rings (n = 169) and Medtronic CG FUTURE annuloplasty rings (n = 26) were also used [7].
Surgical techniques | PLP (n = 648) | ALP (n = 273) | BLP (n = 148) | p-value |
Leaflet resection | 354 (55%) | 2 (0.7%) | 40 (3%) | |
Chordal replacement | 75 (12%) | 185 (68%) | 83 (56%) | |
Leaflet folding | 250 (39%) | 47 (17%) | 50 (34%) | |
Edge-to-edge repair | 7 (1%) | 46 (17%) | 35 (24%) | |
Chordal shortening | 21 (3%) | 1 (0.7%) | ||
Chordal transfer | 10 (4%) | 2 (1%) | ||
Commissural closure | 7 (1%) | 20 (7%) | 18 (12%) | |
Annuloplasty ring size | 31.76 |
31.95 |
32.81 |
|
Carpentier-Edwards Physio I/II | 571 (88%) | 183 (67%) | 120 (81%) | |
Sorin Memo 3D | 71 (11%) | 70 (26%) | 28 (19%) | |
Medtronic CG FUTURE | 6 (1%) | 20 (7%) | 0 (0%) |
PLP, posterior leaflet prolapse; ALP, anterior leaflet prolapse; BLP, bileaflet prolapse.
Table 4 shows the echocardiographic data before patient discharge. The left atrial diameter, left ventricular end-diastolic diameter; left ventricular end-systolic diameter; and ejection fraction was not significantly different between the groups.
Variables | PLP (n = 648) | ALP (n = 273) | BLP (n = 148) | p-value |
Echocardiographic data | ||||
LAD (mm) | 38.15 |
38.00 |
37.59 |
0.402 |
LVEDD (mm) | 48.62 |
49.07 |
49.04 |
0.473 |
LVESD (mm) | 33.21 |
33.81 |
33.55 |
0.342 |
EF (%) | 58.98 |
58.82 |
58.78 |
0.736 |
More than mild MR | 18 | 14 | 8 | 0.306 |
PHT | 15 | 18 | 4 | 0.228 |
PLP, posterior leaflet prolapse; ALP, anterior leaflet prolapse; BLP, bileaflet prolapse; LAD, left atrial diameter; LVEDD, left ventricular end-diastolic diameter; LVESD, left ventricular end-systolic diameter; EF, ejection fraction; MR, mitral regurgitation; PHT, pulmonary hypertension.
During a mean follow-up of 5 years (5–7 years), Nearly 5% (53/1059) of patients were lost during follow-up. And 33 patients died, among whom 23 had PLP, 6 had ALP, and 4 had BLP. Cardiac deaths totaled 14 in the PLP group due to heart failure (n = 9), myocardial infarction (n = 2), sudden unexplained death (n = 2), and infective endocarditis (n = 1); 5 in the ALP group due to heart failure (n = 1), sudden unexplained death (n = 1), and infective endocarditis (n = 1); and 2 in the BLP group due to heart failure (n = 1) and infective endocarditis (n = 1).
Fig. 1 shows the long-term survival of patients with ALP, BLP, and PLP. The
10-year overall survival was 93
Overall survival for isolated anterior, bileaflet, and posterior leaflet prolapse repair. BLP, bileaflet prolapse; ALP, anterior leaflet prolapse; PLP, posterior leaflet prolapse.
Overall, 13 patients underwent reoperation, among whom 7 had PLP, 5 had ALP, and
1 had BLP. The long-term freedom from reoperation rates were 96.8
Cumulative incidence of reoperation for isolated anterior, bileaflet, and posterior leaflet prolapse repair. BLP, bileaflet prolapse; ALP, anterior leaflet prolapse; PLP, posterior leaflet prolapse.
119 patients had mitral valve regurgitation during follow up , including 82
patients with moderate MR and 37 patients with severe MR, among whom 61 had PLP
(19 had severe MR), 42 had ALP (11 had severe MR), and 16 had BLP (7 had severe
MR). The long-term freedom from recurrent MR rates for PLP, ALP, and BLP was 72.4
Fig. 3 shows the cumulative incidences of recurrent MR between PLP, ALP, and BLP. ALP may be a greater risk factor for long-term recurrent MR compared to PLP.
Cumulative incidence of recurrent mitral regurgitation for isolated anterior, bileaflet, and posterior leaflet prolapse repair. BLP, bileaflet prolapse; ALP, anterior leaflet prolapse; MR, Mitral regurgitation; PLP, Posterior leaflet prolapse.
In our institution, patients were asked to have echocardiography 1 month, 6 months and 1 year after operation at our hospital. If there was nothing wrong, patients could have echocardiography once a year at the local hospitals. And 787 patients had undergone echocardiography, and 467 patients underwent echocardiography in our hospital.
Table 5 shows that the pathology of mitral valve is not a risk factor of long-term survival. Table 6 shows that after adjusting for confounding variables via the competitive risk model, the BLP repair had a comparable long-term durability to ALP and PLP repair. Notably, however, PLP repair had better long-term durability than ALP repair.
Univariate analysis | Multivariate analysis | |||
HR (95% CI) | p-value | HR (95% CI) | p-value | |
Age | 1.05 (1.01–1.08) | 0.019 | 1.04 (1.00–1.08) | 0.047 |
Atrial fibrillation | 2.30 (1.08–4.91) | 0.030 | ||
LVESD |
2.48 (1.17–5.28) | 0.018 | ||
EF |
3.46 (1.62–7.39) | 0.001 | 3.09 (1.43–6.65) | 0.040 |
Leaflet prolapse (PLP) | ||||
ALP | 1.30 (0.61–2.76) | 0.49 | ||
BLP | 1.23 (0.44–3.46) | 0.69 | ||
Maze surgery | 2.60 (1.22–5.53) | 0.013 |
HR, hazard ratio; CI, confidence interval; EF, ejection fraction; LVESD, left ventricular end-systolic diameter; ALP, anterior leaflet prolapse; BLP, bileaflet prolapse; PLP, posterior leaflet prolapse.
Univariate analysis | Multivariate analysis | |||
HR (95% CI) | p-value | HR (95% CI) | p-value | |
Age | 1.02 (1.00–1.03) | 0.034 | 1.02 (1.00–1.03) | 0.047 |
Sex | 1.65 (1.15–2.36) | 0.006 | 1.55 (1.08–2.22) | 0.017 |
BMI | 0.92 (0.88–0.97) | 0.003 | 0.93 (0.89–0.98) | 0.0082 |
Atrial fibrillation | 1.41 (0.98–2.03) | 0.063 | ||
E wave velocity | 1.01 (1.00–1.01) | 0.003 | 1.01 (1.00–1.01) | 0.0046 |
Leaflet prolapse (PLP) | ||||
ALP | 1.75 (1.18–2.60) | 0.0057 | 1.640 (1.07–2.52) | 0.024 |
BLP | 1.28 (0.79–2.08) | 0.310 | 1.34 (0.831–2.16) | 0.230 |
Pulmonary hypertension | 1.32 (1.11–1.58) | 0.002 | ||
Residual MR post-surgery | 1.87 (1.21–2.90) | 0.005 | 1.68 (1.08–2.62) | 0.020 |
CPB time | 1.00 (1.00–1.01) | 0.034 | ||
Aortic clamping time | 1.00 (1.00–1.01) | 0.031 |
HR, hazard ratio; CI, confidence interval; BMI, body mass index; PLP, posterior leaflet prolapse; ALP, anterior leaflet prolapse; BLP, bileaflet prolapse; MR, mitral regurgitation; CPB, cardiopulmonary bypass.
In this retrospective study, we found that the rates of long-term survival and
freedom from reoperation did not differ between ALP, BLP, and PLP. Compared to
PLP repair, ALP had a higher probability of having recurrent MR (p
Degenerative mitral valve disease is one of the most common heart valve diseases in the world. Outcomes among ALP, PLP, and BLP repair have been compared for years. Mohty et al. [8] may have been the first to analyze a large series of patients who underwent MVr and report their long-term follow-up results. They found that the reoperation rate was higher for ALP than for PLP. David et al. [9] also reported that the results of PLP repair were better than those of both ALP and BLP repairs. However, the outcomes of ALP repair have also improved with the increase in its usage and the development of repair technology. Castillo et al. [10] reported that they could achieve a near 100% repair rate, regardless of ALP or BLP, while Bonis et al. [11] demonstrated similar long-term results regarding MVr for ALP and PLP. All patients had similar survival and reoperation rates; however, the rate of freedom from recurrent MR was not compared.
The safety and efficacy of MVr for DMR have already been confirmed. However, the
durability of ALP, PLP, and BLP repair remains unclear. Brescia et al.
[12] conducted a retrospective, propensity-matched analysis and found that the
long-term survival and reoperation rates, as well as the MR grade, were not
significantly different between the two groups. Here, we conducted this
retrospective investigation to compare the outcomes of ALP and PLP repair. We
found that if we divided the patients into a complex group (ALP and BLP) and a
simple group (PLP), after adjusting confounding factors with the competitive risk
model, the long-term durability between the two groups was not significantly
different (p
PLP repair has been standardized and has demonstrated excellent long-term outcomes [16]. In contrast, ALP and BLP repairs are considered more challenging and diverse. Carpentier’s technique [17], the edge-to-edge technique, and chordal replacement with polytetrafluoroethylene sutures have all been used for the repair of ALP and BLP. As the second largest cardiac surgery center in China, we have gained considerable experience in ALP repair. In our experience, Carpentier’s technique combined with chordal replacement is an effective method of ALP repair, and the edge-to-edge technique may be a useful rescue technique for failed repair [18]. Earlier, we used to perform some edge-to-edge techniques for ALP repair, and most patients had recurrent MR during follow-up. Nowadays, artificial chordal implantation is the basic measure of ALP repair. Finding the suitable length and number of neochordaes is the key point in performing this procedure. Briefly, the TEE during operation measures the distance between the papillary muscle and the coaptation with the normal leaflet, which guides us to estimate the length of the neochordae. Consequently, the neochordae are placed between the papillary muscle and the free margin of the leaflet. The length can then be adjusted using a forceful saline injection into the left ventricle. Valve competence is evaluated at the same time. As such, 2–3 neochordae may be suitable for ALP repair, but BLP repair may need more. Based on this procedure, we suspect that the dimension of the left ventricle might have decreased postoperatively, leading to an unsuitable length of the neochordae. Eventually, this process is likely to cause recurrent MR and may explain why ALP had low durability.
It is generally accepted that MVr is superior to MVR for degenerative MR [19], and guidelines recommend early surgery for patients with preserved heart function [20]. However, early surgery for patients with ALP and BLP is challenging [21], and outcomes vary among different hospitals [22, 23]. Our results revealed that ALP and BLP repairs can yield excellent results. Some patients may have an imperfect repair with more than mild MR after the operation, and some may develop moderate and severe MR years later. Therefore, surgeons need to be more careful when performing MVr and pay more attention to the TEE results. Early surgery should be recommended only with durable repairs.
This is a retrospective observational study performed at a single center. The sample size is not large enough, especially for the patients with BLP, which may cause bias. The longest period of follow-up is 10 years, we are unabled to obtain very long-term outcomes.We also can not obtain all patients’ echocardiograms during follow-up, which may impact assessment of the duribiity of mitral valve repair. This retrospective observational study is the summary of our previous jobs. And prospective research about DMR is also underway.
Degenerative MR repair can achieve excellent results. The rates of long-term survival and freedom from reoperation were not significantly different among ALP, BLP, and PLP patients. ALP repair still has higher cumulative incidences of recurrent MR compared to PLP. For these patients, surgeons should be more careful.
All relevant data are provided in the manuscript.
KL conceptualized and supervised the study, wrote the original draft, and edited its subsequent versions. QY and JH contributed to the investigation and methodology of the study. YZ, CZ, LS, YL, CB, and SW curated and analyzed the data. JW contributed to the investigation and methodology of the study and supervised the study. QY, YZ, CZ, LS, YL, CB, JH, SW and JW revising it critically for important intellectual content.All authors read and approved the final manuscript. All authors have participated sufficiently in the work and agreed to be accountable for all aspects of the work.
This study conformed to the tenets of the Declaration of Helsinki and was approved by our institution’s human research committee (ID 2022034X). All patients provided informed consent to participate.
Not applicable.
This research received no external funding.
The authors declare no conflict of interest.
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