From January 1987 to July 1994, 299 consecutive patients ranging from 4 to 80 years of age underwent mitral repair for pure valve insufficiency due to degenerative disease (59%), rheumatic disease (23%), endocarditis (12%) or ischemic heart disease (6%). During the initial period, a variety of reparative methods were used following the principles originally described by Carpentier. More recently, in our institution other surgical techniques have been introduced: specifically, prolapse of the anterior leaflet was corrected either by replacing the chordae with polytetrafluoroethylene (PTFE) sutures or simply by anchoring the prolapsing free edge to the facing edge of the posterior leaflet ("edge-to-edge" technique). Chordal transposition has also been used occasionally to correct the prolapse of the anterior leaflet. The hospital mortality rate was 1.3%. According to actuarial methods, the overall survival rate was 94% at 7 years, and freedom from reoperation was 86%. Significant incremental risk factors for reoperation were: no use of prosthetic ring, correction of the prolapse of the anterior leaflet by triangular resection or chordal shortening and ischemic etiology of the mitral insufficiency (freedom from reoperation at 7 years was 61%, 56% and 51%, respectively). In the late postoperative period (mean follow-up 3.6 years), 95% of the patients were in NYHA class I or II; four patients had thromboembolic episodes, two hemorrhagic complications and two endocarditis. No patient in whom the prolapse of the anterior leaflet was corrected by the recently introduced technique has required reoperation. The anterior mitral leaflet prolapse was therefore neutralized as an incremental risk factor for reoperation and this has contributed to the improved overall results of mitral valve repair.

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Our study suggests that PPL occurs more frequently at antero-lateral and postero-medial segments of MVA. This finding might be linked to unusual anatomical and functional factors of the MVA and may call for adjunctive care to these sectors of MVA when performing suture placement during MVR.

The mitral valve was approached through a vertical transeptal incision extended into the roof of the left atrium in 111 patients. Good exposure was invariably provided even in unfavorable situations such as a small left atrium combined with right ventricular hypertrophy or a previously implanted aortic prosthesis. The only hospital death in the entire series was not related to this approach to the mitral valve. Due to breakage of the suture in the roof of the left atrium and to incomplete reconstruction of the atrial septum resulting in a large left-to-right shunt, 2 patients required reinstitution of cardiopulmonary bypass. Both had a smooth postoperative course. Other intra- or postoperative complications related to the incision did not occur. Duration of cardiopulmonary bypass and aortic occlusion was not significantly different from that of patients operated upon through the conventional left atrial approach in the year preceding the experience embraced by this study. Only 3 of 52 patients who were preoperatively in sinus rhythm were discharged in atrial fibrillation. Enhanced atrial vulnerability was demonstrated preoperatively in all 3. These data support a wide application of the extended vertical transeptal approach in mitral valve surgery.

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