A new approach to mitral valve repair for rheumatic disease: preliminary study

The initial application of repair to rheumatic mitral disease was fraught with unacceptable recurrence rates. For this reason, rheumatic valves primarily have been replaced in recent years. Early and late outcomes with replacement, however, have continued to be suboptimal, prompting a re-examination of repair.

All eight patients encountered by the authors with rheumatic mitral valve disease over the past three years were considered for valve repair. One patient had pure stenosis, three patients had pure regurgitation, and four had advanced forms of mixed stenosis and regurgitation. Because posterior leaflet retraction was a prominent and almost uniform feature of rheumatic disease, posterior leaflet glutaraldehyde-fixed autologous pericardial gussets were placed in all cases. In the five patients with stenosis, commissural calcium was debrided, the thickened chords to the anterior leaflet were resected, extended commissurotomies performed, and an anterior leaflet 'hinge' mechanism restored. The anterior leaflet then was reattached to the base of the papillary muscles using Gore-Tex artificial chords, and all eight patients had full ring annuloplasties.

Postoperatively, all patients had negligible gradients and no residual leak. The first patient (with mixed stenosis and regurgitation) was restudied with transesophageal echocardiography after three years, and had continued excellent valve function. There have been no intermediate-term recurrences, complications or mortalities. Operative videos and echocardiograms from these patients are available at JScottRankinMD.com.

A combination of pericardial posterior leaflet gusset, anterior leaflet chordal resection/GoreTex replacement, extended commissurotomy and full ring annuloplasty allows the repair of rheumatic valves over a full range of pathologies. Early and intermediate-term results appear satisfactory. Continued aggressive application of this type of repair to rheumatic mitral disease seems to be indicated.