Commissural closure for the treatment of commissural mitral valve prolapse or flail

Mitral regurgitation (MR) due to commissural prolapse/flail represents a challenging surgical problem for which a variety of reconstructive approaches have been proposed. The study aim was to report the authors' experience with commissural closure within such a difficult setting.

Between 1998 and July 2007, a total of 115 patients (mean age 56.5 +/- 15.5 years) with MR due to pure commissural prolapse/flail of one or both leaflets underwent commissural closure associated with annuloplasty. The etiology of the disease was degenerative in 90.4% of cases and post-endocarditis in 9.6%. The commissural region involved by chordal rupture/elongation was the posterior-medial in 88 patients (76.5%) and the anterior-lateral in 27 (23.5%). The mean NYHA class was 1.9 +/- 0.8, and mean ejection fraction 58.2 +/- 7.7%.

There was one in-hospital death (0.9%). Among patients undergoing isolated mitral repair, the cardiopulmonary bypass and cross-clamp times were 58 +/- 11.6 min and 43 +/- 11.7 min, respectively. Actuarial survival at one and five years was 96.1 +/- 2.2% and 91 +/- 5.3%, respectively. At a mean follow up of 2.3 +/- 1.98 years (median 2.0; range: 1-8.3 years), two patients underwent mitral valve replacement for recurrence of severe MR. At the most recent echocardiographic study (performed in 108 patients), MR was absent in 60 patients (55.6%), mild in 43 (39.8%), moderate in three (2.8%) and severe in two (1.9%, both reoperated on). The mean mitral valve area was 2.8 +/- 0.63 cm2, and the mitral gradient 4.2 +/- 1.05 mmHg.

Commissural prolapse/flail of the mitral valve can be effectively corrected by suturing together the margins of the anterior and posterior leaflets in the commissural area. This type of repair is not time-consuming, and is easily reproducible and durable. In the authors' experience of this surgery, no signs of mitral stenosis were ever detected.