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Reply: Science and judgment in mitral repair: The proof is in the pudding

Published:November 22, 2022DOI:https://doi.org/10.1016/j.jtcvs.2022.10.040
      Reply to the Editor:
      Dr McCarthy reported Edwards Lifesciences: speaking fees and royalties; Medtronic and AtriCure: speaking fees; Abbott: surgical primary investigator, REPAIR-MR trial, and egnite: advisory board.
      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.
      We appreciate the comments from Dr Lawrie, who pioneered the “American Correction.”
      • Lawrie G.
      • Zoghbi W.
      • Little S.
      • Shah D.
      • Earle N.
      • Earle E.
      One hundred percent reparability of mitral prolapse: results of a dynamic nonresectional technique.
      ,
      • Lawrie G.M.
      Mitral measurement: all or nothing?.
      We are aligned on the importance of standardizing mitral repair for the best immediate, and long-term, results. Like Dr Lawrie, we always use a complete remodeling ring; he chooses one that is fully flexible, and we use one that is semiflexible. We differ in the importance of chord preservation. More recent acute animal studies using sophisticated echo imaging, including strain analysis, show no difference in postoperative left ventricular function between leaflet resection and neochord replacement.
      • van 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.
      More importantly, clinical outcomes at 19 and 20 years' follow-up reported little difference in reoperation or recurrent mitral regurgitation in Dr David's series including many patients with neochords or Dr Alfieri's group using resection.
      • David T.E.
      • David C.M.
      • Tsang W.
      • Lafreniere-Roula M.
      • Manlhiot C.
      Long-term results of mitral valve repair for regurgitation due to leaflet prolapse.
      ,
      • Lapenna E.
      • Del Forno B.
      • Amore L.
      • Ruggeri S.
      • Iaci G.
      • Schiavi D.
      • et al.
      Durability at 19 years of quadrangular resection with annular plication for mitral regurgitation.
      In our series, we report 0.3% systolic anterior motion (none needing reoperation or intervention), 10-year need for reoperation of 0.3% (none for recurrent prolapse), and more-than-moderate mitral regurgitation in only 1.4%.
      • McCarthy P.M.
      • Herborn J.
      • Kruse J.
      • Liu M.
      • Andrei A.C.
      • Thomas J.D.
      A multiparameter algorithm to guide repair of degenerative mitral regurgitation.
      The proof is in the pudding. We don't like to rely upon judgment, such as the proper inflation of the ventricle to achieve early isovolumic coaptation, or to risk that a perfect repair may leak months or years later when the dilated ventricle remodels and now the neochords are too long. In the hands of experts with extensive experience, such as Dr Lawrie, late results are excellent with both approaches. However, using data and some measurements (2 are key; A2 and C-sept [the shortest distance between the coaptation point at end-systole and the interventricular septum]) is not a burden on the mitral repair surgeon.
      • Gillinov A.M.
      • Burns D.J.P.
      • Wierup P.N.
      Commentary: mitral valve repair: voodoo, art, and science.
      We would never consider doing a transcatheter aortic valve replacement without using the exact measurements provided by the preoperative computed tomography scan to guide transcatheter aortic valve replacement valve choice and implantation. Mitral repair should be guided by precise data in a similar fashion. Mitral repair was invented in the last century, but our approach could benefit from a reboot.

      References

        • Lawrie G.
        • Zoghbi W.
        • Little S.
        • Shah D.
        • Earle N.
        • Earle E.
        One hundred percent reparability of mitral prolapse: results of a dynamic nonresectional technique.
        Ann Thorac Surg. 2021; 112: 1921-1928
        • Lawrie G.M.
        Mitral measurement: all or nothing?.
        J Thorac Cardiovasc Surg. October 22, 2022; ([Epub ahead of print])
        • van 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. 2022; 164: 1488-1497.e1483
        • David T.E.
        • David C.M.
        • Tsang W.
        • Lafreniere-Roula M.
        • Manlhiot C.
        Long-term results of mitral valve repair for regurgitation due to leaflet prolapse.
        J Am Coll Cardiol. 2019; 74: 1044-1053
        • Lapenna E.
        • Del Forno B.
        • Amore L.
        • Ruggeri S.
        • Iaci G.
        • Schiavi D.
        • et al.
        Durability at 19 years of quadrangular resection with annular plication for mitral regurgitation.
        Ann Thorac Surg. 2018; 106: 735-741
        • McCarthy P.M.
        • Herborn J.
        • Kruse J.
        • Liu M.
        • Andrei A.C.
        • Thomas J.D.
        A multiparameter algorithm to guide repair of degenerative mitral regurgitation.
        J Thorac Cardiovasc Surg. 2022; 164: 867-876.e5https://doi.org/10.1016/j.jtcvs.2020.09.129
        • Gillinov A.M.
        • Burns D.J.P.
        • Wierup P.N.
        Commentary: mitral valve repair: voodoo, art, and science.
        J Thorac Cardiovasc Surg. 2022; 164: 878-879https://doi.org/10.1016/j.jtcvs.2020.10.043

      Linked Article

      • Mitral measurement: All or nothing?
        The Journal of Thoracic and Cardiovascular Surgery
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          The recent report of McCarthy and colleagues1 highlights several important points. The authors have reminded us that the national surgical repair rate for regurgitant mitral valves of 82% is well below rates achieved in centers of excellence. They attribute this to the complexity of the mitral repair techniques described by Carpentier, who has advocated multiple variants of leaflet resection to treat prolapsing segments and correct “excessive leaflet size.” McCarthy and colleagues noted that the surgeons in these experienced centers speak of having had to master what they refer to as not only the science but also the “art” of mitral valve repair.
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