Time to rest on our laurels or escape our bed of thorns?

To the Editor:The author reported no conflicts of interest.The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest. The author reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest. Tomsic and colleagues1van Wijngaarden A.L. Tomsic A. Mertens B.J.A. Fortuni F. Delgado V. Bax J.J. et al.Mitral valve repair for isolated posterior mitral valve leaflet prolapse: the effect of respect and resect techniques on left ventricular function.J Thorac Cardiovasc Surg. February 23, 2021; ([Epub ahead of print])Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar have presented data on 2 groups of patients who underwent repair of posterior leaflet prolapse: a resect group of 82 patients and a respect group of 43 patients. In the resect group, a variety of resections were performed but notably 41 (50%) patients also underwent chordal replacement in keeping with the title of the article: “respect and resect.” In the respect group, polytetrafluoroethylene neochordae were used as described by Perier.2Perier P. A new paradigm for the repair of posterior leaflet prolapse: respect rather than resect.Op Tech Thorac Cardiovasc Surg. 2005; 10: 180-193Abstract Full Text Full Text PDF Scopus (36) Google Scholar He advocated replacement of posterior leaflet resection with the use of neochordae implanted and adjusted to immobilize the posterior leaflet in a way that produced changes in leaflet motion similar to quadrantic resection. He reported that “most of the time echocardiographic results after valve repair shows a posterior leaflet with little or no mobility hanging vertically from the annulus and forming, as shown experimentally, a buttress against which the anterior leaflet comes in apposition.”2Perier P. A new paradigm for the repair of posterior leaflet prolapse: respect rather than resect.Op Tech Thorac Cardiovasc Surg. 2005; 10: 180-193Abstract Full Text Full Text PDF Scopus (36) Google Scholar Both groups received the same semirigid annuloplasty rings. Thus, it is consistent with the known similarities of the effects of these techniques at the leaflet and annular level, that the authors found that left ventricle performance was similar in both groups. The absence of a normal control group is a limitation of the study. Alternatively, neochordae can be used to restore normal leaflet motion, not create immobility.3Ben Zekry S. Freeman J. Jajoo A. He J. Little S.H. Lawrie G.M. et al.Patient-specific quantitation of mitral valve strain by computer analysis of three-dimensional echocardiography.Circ Cardiovasc Imaging. 2016; 9: e003254Crossref PubMed Scopus (20) Google Scholar Normal leaflet motion requires intact unresected leaflets and normal annular motion, preserved by the use of fully flexible rings.4Ben Zekry S. Jain S. Alexander S.K. Li Y. Aggarwal A. Jajoo A. et al.Novel parameters of global and regional mitral annulus geometry in man: comparison between normal and organic mitral regurgitation, before and after mitral valve repair.Eur Heart J Cardiovasc Imaging. 2016; 17: 447-457Crossref PubMed Scopus (12) Google Scholar Techniques based on these principles are applicable to all leaflet segments, not just the posterior leaflet. Our own comparison of restorative use of neochordae and flexible rings compared with leaflet resection showed better preserved annular function, superior leaflet motion, larger annuloplasty ring sizes, and lower transmitral gradients using these techniques.5Ben Zekry S. Lang R.M. Sugeng L. McCulloch M.L. Weinert L. Raman J. et al.Mitral annulus dynamics early after valve repair: preliminary observations of the effects of resectional versus non-resectional approaches.J Am Soc Echocardiogr. 2011; 24: 1233-1242Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar These studies suggest that the full benefits of chordal replacement will not be recognized unless combined with restoration of normal mitral annular and left ventricular outflow tract function. Thus, descriptions of the use of neochordae should specify in what context they are being used, as was done by Tomsic and colleagues.1van Wijngaarden A.L. Tomsic A. Mertens B.J.A. Fortuni F. Delgado V. Bax J.J. et al.Mitral valve repair for isolated posterior mitral valve leaflet prolapse: the effect of respect and resect techniques on left ventricular function.J Thorac Cardiovasc Surg. February 23, 2021; ([Epub ahead of print])Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar This study has provided reassuring data regarding postoperative left ventricle function measured by global longitudinal strain in patients undergoing treatment of localized posterior leaflet prolapse. However, I believe it is premature to suggest that this study proves equivalence and interchangeability between leaflet resection and neochordal replacement in general. The extent to which complete reparability can be achieved and left ventricular outflow tract performance preserved, including the incidence of systolic anterior movement, were not addressed in this study. The authors are to be commended for their efforts to advance our knowledge toward the goal of successful mitral repair for all eligible patients. Mitral valve repair for isolated posterior mitral valve leaflet prolapse: The effect of respect and resect techniques on left ventricular functionThe Journal of Thoracic and Cardiovascular SurgeryPreviewPosterior mitral valve leaflet prolapse repair can be performed by leaflet resection or chordal replacement techniques. The impact of these techniques on left ventricular function remains a topic of debate, considering the presumed better preservation of mitral-ventricular continuity when leaflet resection is avoided. We explored the effect of different posterior mitral valve leaflet repair techniques on postoperative left ventricular function. Full-Text PDF Open AccessReply from authors: Many roads lead to RomeJTCVS OpenVol. 8PreviewWe would like to thank Lawrie and DeBakey1 for their insightful comments on our article. A rightful observation made by the authors is the use of neochords in a proportion of patients from the “resect” group. In our opinion, leaflet resection and chordal-replacement techniques are not completely interchangeable but rather complementary. Both techniques, and often a combination of these, are needed to achieve the optimal results of reconstructive mitral valve surgery, a view previously emphasized by our group. Full-Text PDF Open Access