Mitral valve repair in myxomatous bileaflet mitral valve prolapse: Resectional versus non-resectional ring-only approaches

Simple mitral valve repair (MVR) using a ring-only approach (ROA) was recently proposed for some complex forms of myxomatous bileaflet mitral valve prolapse (MMVP). Nevertheless, few data are available concerning the characteristics of MMVP patients that may benefit from this simple repair technique. Based on 39 consecutive patients (28 men; mean age 57 ± 15) with severe primary Mitral regurgitation (MR) caused by bileaflet MMVP referred for MVR, we sought to (i) identify the clinical and echocardiographic predictors of a ROA (ii) to assess the postoperative clinical outcomes and valve function. 23 patients (59%) underwent standard resectional MVR (SMVR) while 16 (41%) underwent ROA. Cardiopulmonary bypass and cross clamp times were lower in ROA than in SMVR (74 ± 27 min vs. 99 ± 42 min and 70 ± 25 min vs. 49 ± 19 min, respectively, P = 0.03 and P = 0.005). None of the patients died in the postoperative period. Occurrence of stroke and postoperative atrial fibrillation was similar between groups. ROA patients were more frequently women (50% vs. 13%, P = 0.027). Echocardiographic predictors of successful ROA were prolapsing depth < 10 mm, absence of flail leaflet and ruptured chordae, presence of multiple jets, more often in the central part of the valve (A2P2). Mid-late systolic MR and paradoxical systolic annulus expansion (PAE) were also associated with ROA. The repaired valves showed mild pressure gradient of 3 ± 1 mmHg. Non hemodynamic systolic anterior motion and residual trivial MR tended to be more frequent in ROA than in SMVR (12% vs. 4%, P = 0.37 and 31% vs 18%; P = 0.35, respectively). ROA was more frequently associated with preservation of postoperative posterior leaflet mobility (75% vs. 18%, P = 0.0001). Simple and fast MVR using a ROA is feasible in 4/10 patients with complex forms of bileaflet MMVP, with good immediate results. Predictors of ROA were female gender, mid-late systolic central multiple jet, low prolapse depth, absence of chordal rupture or flail leaflet and PAE.