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• W2997102579 abstract "Central MessageMitral valve repair is the procedure of choice for all patients with mitral valve prolapse.See Article page 1087. Mitral valve repair is the procedure of choice for all patients with mitral valve prolapse. See Article page 1087. Mitral valve repair is superior to mitral valve replacement in patients with degenerative mitral valve disease. Available data comparing repair with replacement support this statement, and few would disagree.1Gillinov A.M. Blackstone E.H. Nowicki E.R. Slisatkorn W. Al-Dossari G. Johnston D.R. et al.Valve repair versus valve replacement for degenerative mitral valve disease.J Thorac Cardiovasc Surg. 2008; 138: 885-893Abstract Full Text Full Text PDF Scopus (205) Google Scholar,2Anyanwu A.C. Bridgewater B. Adams D.H. The lottery of mitral valve repair surgery.Heart. 2010; 05: 1964-1967Crossref Scopus (56) Google Scholar Because the majority of patients with degenerative disease have posterior leaflet prolapse, most of the data supporting the benefits of mitral valve repair are based on the results of posterior leaflet/chordal repair. In this issue of the Journal, Brescia and colleagues3Brescia A.A. Watt T.M.F. Rosenbloom L.M. Murray S.L. Wu X. Romano M.A. et al.Anterior versus posterior leaflet mitral valve repair: a propensity-matched analysis.J Thorac Cardiovasc Surg. 2021; 162: 1087-1096.e3Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar from the University of Michigan present data to support mitral valve repair in those with anterior (or bileaflet) prolapse, as well. Comparing propensity-matched patients who underwent anterior leaflet repair with those who had posterior leaflet repair, Brescia and colleagues found no difference in residual mitral regurgitation, survival, or freedom from reoperation. At 15 years' follow-up, mitral valve reoperation occurred in 7.5% of those with anterior leaflet prolapse and in 4.9% of those with posterior leaflet prolapse; these figures were not statistically different. Based on these excellent results, the authors concluded that surgeons should approach anterior leaflet prolapse as they do posterior leaflet prolapse; to wit, surgeons should repair the valve. Despite the excellent results reported by Brescia and colleagues, surgeons regard anterior leaflet repair as a particular challenge that yields uncertain results. Why do surgeons perceive a problem with the anterior leaflet? Several factors explain this perspective. Isolated anterior leaflet prolapse is far less common than posterior leaflet prolapse, meaning that surgeons have less experience with such valves. Compounding this, anterior leaflet repair is traditionally more challenging than posterior leaflet repair. When creating neochordae, determination of chordal length can be difficult. In addition, many patients with isolated anterior leaflet prolapse have diminutive posterior leaflets, rendering it difficult to achieve good leaflet coaptation. Given these surgical challenges and the general perception that anterior repairs have limited durability, some surgeons may favor replacement in these patients. Although Brescia and colleagues do not provide their repair rates in patients with anterior leaflet prolapse, we can presume that they are quite high in their center (ie, >90% across all subsets of prolapse). Their excellent intraoperative and long-term results confirm that repair of anterior prolapse is both feasible and advisable in experienced surgical hands. This supports early referral of all patients with severe mitral regurgitation caused by degenerative disease, regardless of the site of prolapse. After a successful repair, the majority of patients will never need mitral valve surgery again; in addition, they experience low rates of valve-related morbidity.4David T.E. David C.M. Tsang W. Lafreniere-Roula M. Manlhiot C. Long-term results of mitral valve repair for regurgitation due to leaflet prolapse.J Am Coll Cardiol. 2019; 74: 1044-1053Crossref PubMed Scopus (111) Google Scholar At this point, experienced surgeons should aim to repair virtually all degenerative valves and should have little problem with the anterior mitral leaflet.5Suri R.M. Schaff H.V. Dearani J.A. Sundt T.M. Dalcy R.C. Mullany C.J. et al.Survival advantage and improved durability of mitral repair for leaflet prolapse subsets in the current era.Ann Thorac Surg. 2006; 82: 819-826Abstract Full Text Full Text PDF PubMed Scopus (362) Google Scholar Anterior versus posterior leaflet mitral valve repair: A propensity-matched analysisThe Journal of Thoracic and Cardiovascular SurgeryVol. 162Issue 4PreviewMitral valve repair is superior to replacement for degenerative disease, but long-term outcomes of anterior versus posterior leaflet repair remain poorly defined. We propensity matched anterior and posterior repairs to compare long-term outcomes. Full-Text PDF" @default.
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• W2997102579 title "Commentary: A problem with the anterior mitral leaflet?" @default.
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