Anterior leaflet repair with patch augmentation for mitral regurgitation.

BACKGROUND: Anterior leaflet repair continues to pose significant operative challenges, particularly in patients with retracted or "short" anterior leaflets, due to rheumatic or radiation induced mitral valve disease. This often results in abandonment of repair in favor of mitral valve replacement, requiring anticoagulation and altering left ventricular (LV) function and geometry. This study examines our experience of anterior leaflet repair with patch augmentation.

METHODS: Forty-two patients underwent mitral valve repair for a shortened anterior leaflet from 1994 to 2003. Twenty-two patients with a mean age of 53 +/- 6 years had radiation valvulitis (XR) whereas 20 patients, age 28 +/- 7 years had rheumatic heart disease (RHD). Those patients with XR had a mean New York Heart Association (NYHA) class of 3.2 +/- 0.4 and an angina score of 2.1 +/- 0.6 compared with a NYHA class 3.8 +/- 0.2 and no angina in RHD patients. All patients presented with severe MR. Anterior leaflet augmentation with a gluteraldehyde-treated, autologous pericardial patch and complete annuloplasty ring was used in all patients. Additionally, extensive subvalvar debridement was performed in RHD patients. Twelve XR patients underwent concomitant CABG with a mean of 2.4 +/- 0.8 grafts/patient. Additional surgical procedures included tricuspid valve repair, anterior septal defect, and aortic valve replacement. Mean follow-up was 39 +/- 10 months for XR patients and 12 +/- 25 months for RHD patients.

RESULTS: There were two late deaths in XR patients from underlying malignancies and no deaths in RHD patients. Two RHD patients required reoperation for recurrent mitral regurgitation at 3 and 20 months. All patients demonstrated clinical improvements (NYHA I-II) following repair. No mitral stenosis was induced.

CONCLUSIONS: Despite anterior leaflet shortening from XR or rheumatic alterations, opportunity still exists for gratifying mitral valve repair. By utilizing anterior leaflet patch augmentation, concomitantly with ring annuloplasty, anticoagulation is avoided, LV geometry is preserved, and follow-up reveals excellent functional improvement.