Mitral valve: toward complete repairability

During the last 50 years, there has been an exponential increase in our understanding of the structure and function of the mitral valve in health and disease. Large numbers of patients have undergone mitral-valve reparative procedures worldwide with variable results. In our initial 10-year experience in which traditional techniques were used for repair of mitral regurgitation, a 70% success rate was achieved. In 1995, a critical reappraisal of the common causes of failure to repair, or failure of repair and developed improved surgical approaches for these patients began. The conditions addressed were massive bileaflet prolapse ("Barlow's valves"); anterior leaflet prolapse; multisegment chordal failure; commissural accessory leaflet tissue prolapse; and leaflet destruction by endocarditis. A widely applicable standard technique was developed that the author and colleagues called the "American Correction." It emphasizes chordal replacement with polytetrafluoroethylene (PTFE) artificial chordae, importance of the line of apposition of the leaflets, and importance of simultaneous dynamic adjustment of the chordal length and anteroposterior dimension of the mitral annulus. In addition, use of multiple techniques in 30% of patients to complete the repair has been emphasized. These techniques resulted in a 90% repairability rate for all pathologies and 100% for myxomatous-mitral insufficiency. These techniques also have led to a decline in reoperation rates, and improved long-term durability. Continued evaluation with intraoperative and postoperative three-dimensional (3-D) echo provides further insights and refinement of mitral-repair techniques.