1. Division of Cardiac Surgery University of Ottawa Heart Institute
Current surgical standards for mitral leaflet or chordal repair: resect vs.respect ?
Thierry Mesana, MD, PhD
Division of Cardiac Surgery
University of Ottawa Heart Institute
Ottawa, Ontario, Canada

2. Thierry Georges Mesana, MD, PhD
I/we have no real or apparent conflicts of interest to report.

3. PL Quadrangular Resection Sliding PL Plasty. No SAM
More Complex
Reconstruction
Triangular Resection
Simpler, Faster
FED > Myxoid
No Excess Tissue
Posterior Leaflet resection/repair
Carpentier
Still a gold standard.

4. Respect. Using Artificial Chords David 1998 First applied to AL
Seems simple
A Plethora of Techniques to adjust Neo-Chords
To implant in PM, to pass the leaflet edge…
Not so easy when extensive MVP
More than one neochord

5. Respect rather than Resect the Anterior Leaflet is a good idea
AL prolapse represents 10-20% of MVP
Plus 20-30% of Bileaflet prolapse
Anterior leaflet resection is rarely indicated (I never do it !)
Chordal transfer is now justified only in Bileaflet Prolapse (basal PL chords to AL)
The current standard to repair isolated AL is chordal replacement (PTFE, Goretex)
Flip-over : segment of the posterior leaflet with its chordae is transferred to the
anterior leaflet
Chordal Transfer from normal PL
Now rarely performed

6. More recently introduced, even simpler
Posterior leaflet artificial chordal replacement
More recently introduced, even simpler
Rankin J. S. et al.; Ann Thorac Surg 2006;81:

7. FREEDOM FROM MITRAL REOPERATION Posterior leaflet only
Ann Thorac Surg 2008;86: , Perrier

8. Folding Plasty No leaflet resection and No neo-chords

9. Edge-to-Edge : Alfieri Technique
Still there 15 years after and basis
of percutaneous Mitraclip.
“no resect, still respect… and no neochord”
Not applicable to all MV pathology.
Localized MVP ( central or commisural)

10. Kuduvalli M. et al.; Ann Thorac Surg 2006;82:1356-1361
Freedom from death or repeat intervention after the Alfieri repair at 5 years
Kuduvalli M. et al.; Ann Thorac Surg 2006;82:
Copyright ©2006 The Society of Thoracic Surgeons

11. IS A CHORDAL APPROACH DURABLE for all prolapse subsets
IS A CHORDAL APPROACH DURABLE for all prolapse subsets? …a word of caution

12. David T. E. et al.; J Thorac Cardiovasc Surg 2003;125:1143-1152

13. Includes 3+ and 4+ MR but not the MR 2+
Freedom from recurrent moderate or severe mitral regurgitation (MR) in all patients
Includes 3+ and 4+ MR but not the MR 2+
David T. E. et al.; J Thorac Cardiovasc Surg 2005;130:
Copyright ©2005 The American Association for Thoracic Surgery

14. David T. E. et al.; J Thorac Cardiovasc Surg 2005;130:1242-1249
Freedom from recurrent moderate or severe mitral regurgitation (MR) in patients with posterior (PL), anterior (AL), and bileaflet (BL) prolapse
David T. E. et al.; J Thorac Cardiovasc Surg 2005;130:

15. Flameng W. et al.; J Thorac Cardiovasc Surg 2008;135:274-282
Resection technique durability varies with anatomy
FED vs Barlows
No sliding as surgical risk
Flameng W. et al.; J Thorac Cardiovasc Surg 2008;135:
Copyright ©2008 The American Association for Thoracic Surgery

16. Spectrum of Degenerative Mitral Valve Disease needs more than one approach
FED
FED+
Form Fruste
Barlow’s + ++
+++
++++
Excess Tissue
Adams et al. Eur Heart J 2010;31:

17. UOHI : BILEAFLET PROLAPSE, in JTCVS 2012
Carpentier techniques + neo chords + Alfieri….
142 patients
2 re-operations
1 Goretex, 1 MS

18. Conclusions 1- Many techniques can work, as far as adequate
line of coaptation is restored, leaflet motion is respected,
and annuloplasty is performed, and no MS is generated
2- Anatomy based : do not ignore excess of tissue
3- One technique does not fit all, long-term and careful FU
in dedicated MV clinic with regular echocardiograms
4- MV prolapse is best treated in expert MV centers

19. Also Respect the Posterior Leaflet ? Increasingly popular
But not yet a gold standard, FED more than Myxomatous
Ann Thorac Surg 2008;86:718-25
Observational
Sympto/asympto
J Thorac Cardiovasc Surg 2008;136:1200-6
65 vs.65 pts
Ann Thorac Surg 2010;89:
397 pts; 205/192
2-year mean FU
Ann Thorac Surg 2009;87:
“ Mini-Mitral”
670 pts. 353/317
2.8 year mean FU