Leaflet extension in rheumatic mitral valve reconstruction

Type IIIa mitral regurgitation (MR) due to rheumatic leaflet restriction often renders valve repair challenging and may predict a less successful repair. However, the utilization of leaflet mobilization and extension with the pericardium to increase the surface of coaptation may achieve satisfactory results. We reviewed our experience with leaflet extension in rheumatic mitral repair with emphasis on the technique and mid-term results.

Between 2003 and 2010, 62 of 446 rheumatic patients had leaflet extension with glutaraldehyde-treated autologous pericardium as part of their mitral repair procedure. Their clinical and echocardiographic data were prospectively analysed.

The mean age of the rheumatic patients was 20.2 ± 11.7 years; range 3-60 years. Fourty-eight (77.4%) patients had predominant MR, while 22.6% had mixed mitral stenosis and mitral regurgitation (MS/MR). Leaflet extension was performed in the posterior, anterior and both leaflets in 77, 13 and 10% of patients, respectively. Additional repair procedures included neo-chordal replacement, chordal transfer/shortening/fenestration/resection, commissurotomy and papillary muscle splitting. All repairs were stabilized with annuloplasty rings. The follow-up was complete in all patients with a mean follow-up of 36.5 ± 25.6 months. There was no mortality in this series. At the latest follow-up, the MR grade was none/trivial in 64.5 of patients, mild in 22.6, moderate in 6.5, moderately severe in 4.8 and severe in 1.6%. Two patients had redo mitral surgery. At 5 years postoperatively, the estimated rates of freedom from reoperation and valve failure were 96.8 and 91.6%, respectively.

Repair with leaflet extension in rheumatic disease resulted in good early and mid-term outcomes. A wider utilization of this technique may increase the feasibility and durability of repair in complex rheumatic mitral valve disease.