Residual Mitral Regurgitation After Repair for Posterior Leaflet Prolapse—Importance of Preoperative Anterior Leaflet Tethering

Abstract

BackgroundCarpentier's techniques for degenerative posterior mitral leaflet prolapse have been established with excellent long‐term results reported. However, residual mitral regurgitation (MR) occasionally occurs even after a straightforward repair, though the involved mechanisms are not fully understood. We sought to identify specific preoperative echocardiographic findings associated with residual MR after a posterior mitral leaflet repair.Methods and ResultsWe retrospectively studied 117 consecutive patients who underwent a primary mitral valve repair for isolated posterior mitral leaflet prolapse including a preoperative 3‐dimensional transesophageal echocardiography examination. Twelve had residual MR after the initial repair, of whom 7 required a corrective second pump run, 4 underwent conversion to mitral valve replacement, and 1 developed moderate MR within 1 month. Their preoperative parameters were compared with those of 105 patients who had an uneventful mitral valve repair. There were no hospital deaths. Multivariate analysis identified preoperative anterior mitral leaflet tethering angle as a significant predictor for residual MR (odds ratio, 6.82; 95% confidence interval, 1.8–33.8; P=0.0049). Receiver operator characteristics curve analysis revealed a cut‐off value of 24.3° (area under the curve, 0.77), indicating that anterior mitral leaflet angle predicts residual MR. In multivariate regression analysis, smaller anteroposterior mitral annular diameter (P<0.001) and lower left ventricular ejection fraction (P=0.002) were significantly associated with higher anterior mitral leaflet angle, whereas left ventricular and left atrial dimension had no significant correlation.ConclusionsAnterior mitral leaflet tethering in cases of posterior mitral leaflet prolapse has an adverse impact on early results following mitral valve repair. The findings of preoperative 3‐dimensional transesophageal echocardiography are important for consideration of a careful surgical strategy.

Impact of Leaflet Tethering on Residual Regurgitation in Patients With Degenerative Mitral Disease After Interventional Edge-to-Edge Repair

“…However, the population of our residual MR 2+ group may be different from that of the mixed/functional MR group in the study by Oguz et al, as our population presented with preserved LV function (LVEF: 50–67% vs. 30–54%) despite LV dilatation. These findings suggest that patients with DMR could evolve to mixed disease via the established vicious cycle ( 7 , 21 ), where DMR causes secondary mitral leaflet tethering by LV dilatation, and leaflet tethering in turn exacerbates MR. More importantly, this subtype of MR poses a challenge to the effectiveness of interventional EE repair.…”

“…Otani et al first reported primary PML prolapse in patients with DMR caused by the outward displacement of papillary muscles due to secondary LV dilatation and therefore AML tethering ( 7 ). AML tethering in patients with PML prolapse was demonstrated to be associated with unfavorable postprocedural residual MR after surgical repair ( 21 ). Moreover, regional leaflet tethering can coexist with prolapse in AML and/or PML and, more importantly, could also affect surgical repair as a risk factor for MR occurrence ( 10 , 11 , 22 ).…”

Association of tethering of the second‐order chords and prolapse of the first‐order chords of the anterior leaflet: A risk factor for early and late repair failure

“…Otani et al 3 reported increased AL tenting in patients with posterior leaflet prolapse, suggesting that second‐order chord tethering could be due to an augmented distance between the papillary muscles, even though in 19 cases out of 25 (76%) left ventricular end‐systolic volume index and left ventricular end‐systolic diameter were within the normal range. Sakaguchi et al 4 analyzed 12 patients with residual MR after correction of posterior leaflet prolapse and found that a preoperative AL angle higher than 24.3° was predictive of residual MR at follow‐up. AL tethering could be due to left ventricular dilation, but it occurred also in normal hearts.…”

“…Second‐order chord tethering of the anterior mitral leaflet (AL) is a widely recognized anatomic aspect that needs to be carefully evaluated in secondary mitral regurgitation (MR) 1,2 . Its importance in primary MR has recently been reported 3‐5 and it has been identified as a risk factor for MR recurrence after correction of posterior leaflet prolapse 4 …”

The impact of intraoperative residual mild regurgitation after repair of degenerative mitral regurgitation

“…1,2 Uncorrected residual (MR still present on intraoperative postpump transesophageal echocardiogram [TEE]) moderate MR has been demonstrated to lead to a significant risk for late progression of MR and need for reoperation, 3,4 but the data on residual mild MR are limited. [5][6][7] Therefore, when faced with residual mild MR after degenerative MR (DMR) repair, the surgeon has little data to guide an important decision, that is, whether to go back on bypass, reclamp and arrest the heart, and try to re-repair the valve, or is it safe and reasonable to accept a small amount of residual mild MR?…”