Repair of anterior leaflet prolapse by papillary muscle repositioning: a new surgical option

Although mitral valve repair is considered the gold standard for treating mitral regurgitation, anterior leaflet prolapse may still remain a challenging problem. This challenge is even greater for posterior commissural prolapse. We have used papillary muscle repositioning to treat anterior leaflet prolapse and suggest it as an alternative technique for all other methods previously described.

From 1989 to 1999 we performed 253 mitral valve repairs, among which 132 involved anterior leaflet prolapse. In this population there were two groups: group I (n = 92) treated with papillary muscle repositioning and group II (n = 40) treated with chordal shortening. There was no statistical difference between the two groups concerning age, functional class, and left ventricular function. Etiology was similar in both groups, a degenerative process being predominant. At echocardiography, regurgitation was graded 3.4/4 in both groups. There was no statistical difference concerning preoperative ejection fraction, end-systolic and end-diastolic left ventricular diameter.

There were one in-hospital death in group I and two deaths in group II not related to mitral valve repair. Mean follow up is 36.4 +/- 29.2 months in group I and 70.5 +/- 9.5 months in group II. No patient was lost to follow-up. Mean regurgitation at follow-up was 0.75 +/- 0.67 in group I and 0.8 +/- 0.8 in group II (p = not significant). There was no statistical difference between the two groups concerning postoperative ejection fraction, end-systolic and end-diastolic left ventricular diameter. There was no late cardiac death in either group and there were no thromboembolic events. Actuarial survival rate is 98.9% and 96.3% in group I and 92.5% and 88.1% in group II at 3 and 8 years, respectively.

Therefore, we conclude that papillary muscle repositioning is a safe technique that provides excellent results at mid-term follow-up and facilitates treatment of anterior leaflet prolapse.