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Long-term results of mitral valve reconstruction for regurgitation of the myxomatous mitral valve

      Abstract

      The myxomatous, degenerated, prolapsed or “floppy” mitral valve is the most common cause of mitral regurgitation in North America. Mitral valve reconstruction for mitral regurgitation was carried out in 219 consecutive patients with a myxomatous mitral valve from 1984 to 1993. Of the 139 men and 80 women, 23 to 84 years of age (mean 63 years), 36% of patients were 70 years of age or older, 77% were in New York Heart Association functional class III or IV, and 29% had coronary artery disease necessitating coronary bypass. The most common operation was posterior leaflet resection (161 patients [73%]). The anterior leaflet was resected in 14 patients, and both the anterior and posterior leaflets were resected in 15 patients. A variety of other techniques were used, including commissuroplasty and use of annuloplasty rings. A flexible Duran ring was used in 111 patients (51%), a Carpentier-Edwards ring in 44 patients (20%), and no ring was used in 64 patients (29%). Five operative deaths occurred (2.3%); four of the five deaths occurred in patients 70 years of age or older (5.1%); and one in 141 patients (0.7%) was younger than 70 years of age. In the late postoperative period (mean follow-up 2 years), 90% of patients had no symptoms, two had endocarditis, and seven patients had thromboemboli (transient in four, permanent in three). Structural valve degeneration requiring reoperation occurred late in 12 patients; eight were in posterior leaflet resection and two in anterior or anterior and posterior; six of 12 had no annuloplasty ring. The incidence of structural valve degeneration was less than 5% from 1990 to 1993. No systolic anterior motion of the mitral valve was seen with postoperative echocardiography before discharge. Actuarial analysis at 5 years for overall survival was 86% ± 5%, freedom from infectious valve degeneration 97% ± 2%, and freedom from thromboembolism 94% ± 3%. Freedom from structural valve degeneration overall was 83% ± 4%, with a flexible ring it was 89% ± 6%, with a rigid ring it was 88% ± 6%, and with no ring it was 67% ± 12% ( p = 0.03). Mitral valve reconstruction for complicated myxomatous disease of the mitral valve, regardless of leaflet involvement, is feasible and offers excellent early and late results. (J T HORAC C ARDIOVASC S URG 1994;107:143-51)
      Myxomatous degeneration of the mitral valve producing the so-called floppy mitral valve is the most common abnormality of human heart valves and is a major cause of mitral regurgitation in North America.
      • Marks AR
      • Choong CY
      • Sanfilippo AJ
      • Ferre M
      • Weyman AE.
      Identification of high-risk and low-risk subgroups of patients with mitral valve prolapse.
      • Nishimura RA
      • McGoon MD
      • Shub C
      • et al.
      Echocardiographically documented mitral valve prolapse: long-term follow-up of 237 patients.
      • Wilcken DEL
      • Hickey AJ.
      Lifetime risk for patients with mitral valve prolapse of developing severe valve regurgitation requiring surgery.
      The leaflets and chordae tendineae stretch as a result of deposition of myxomatous material in the valve leaflets and chordae resulting in mitral valve prolapse, especially of the posterior leaflet.
      • Olson LJ
      • Subramanian R
      • Ackerman DM
      • Orszulak TA
      • Edwards WD.
      Surgical pathology of the mitral valve: a study of 712 cases spanning 21 years.
      Mitral valve prolapse is very common in women 20 to 30 years old, but increases in men with age, often requiring operation for severe mitral regurgitation.
      • Marks AR
      • Choong CY
      • Sanfilippo AJ
      • Ferre M
      • Weyman AE.
      Identification of high-risk and low-risk subgroups of patients with mitral valve prolapse.
      • Nishimura RA
      • McGoon MD
      • Shub C
      • et al.
      Echocardiographically documented mitral valve prolapse: long-term follow-up of 237 patients.
      • Wilcken DEL
      • Hickey AJ.
      Lifetime risk for patients with mitral valve prolapse of developing severe valve regurgitation requiring surgery.
      This report summarizes experience at the Brigham and Women's Hospital, from 1981 to 1993, on mitral valve reparative procedures in patients with isolated mitral regurgitation from myxomatous degeneration.

      PATIENTS AND METHODS

      All patients undergoing mitral valve repair for mitral regurgitation as a result of myxomatous degeneration from January 1981 to March 1993 were reviewed. A total of 360 patients overall with this diagnosis were treated at Brigham and Women's Hospital, 141 with valve replacement. There were 219 patients with mitral valve repair, all of whom had severe mitral regurgitation as determined with preoperative Doppler echocardiography or left ventriculography. Demographics of this patient group are found in Table I. In this series, patients were excluded if they had other major valve lesions, such as aortic valve disease or major tricuspid valve regurgitation. There was a predominance of women, patients with coexistent coronary artery disease, and patients 70 years of age or older. In addition, about one third of the patients had chronic atrial fibrillation. New York Heart Association (NYHA) functional classification is shown in Table II. Patients in functional classification I and II had minimal symptoms and underwent operation either because of marked increase in left ventricular end-diastolic and end-systolic dimensions, as determined by serial echocardiographic examinations, or, for a small number of patients, intermittent atrial fibrillation. The left ventricular ejection fraction was calculated in most, but not all patients, by left ventriculography or echocardiography.
      Table IMitral repair of floppy valve: demographics at Brigham and Women's Hospital 1981-93
      No. of patients219
      M/F139:80
      Age (yr)23-84 (mean 63)
      Age> 7078 (36%)
      Coronary artery disease63 (29%)
      Atrial fibrillation82(38%)
      NYHA functional classification
       I,II 50(23%)
       III,IV169 (77%)
      Table IIMitral repair of floppy valve: demographics at Brigham and Women's Hospital 1981-93
      No. of patients
      NYHA functional classificationPreoperativePostoperative
      I5149
      II4531
      III1363
      IV330

      Operative techniques

      All operations were performed with the use of cardiopulmonary bypass, cold hyperkalemic cardioplegic solution (blood or crystalloid), and a single aortic crossclamp. If concomitant coronary artery bypass grafting was done, the distal coronary artery anastomoses were done before valve repair and perfusion with cardioplegic solution through the distal grafts, and the proximal coronary anastomosis were done after closure of the left atrium. Table III summarizes the operative techniques used in this diverse group of 219 patients according to leaflet resections, adjunctive procedures such as commissuroplasty and chordoplasty, and the type of annuloplasty treatment (ring or no ring).
      Table IIIMitral repair of floppy valve: operative technique
      No. of patientsStructural valve degeneration
      Posterior leaflet resection
       Only388
       Ring plus other1236
      Anterior leaflet resection
       Only2
       Ring plus other123
      Anterior/posterior leaflet resection
       Ring150
      No leaflet resection
       Ring only92
       Ring plus other202
      Total21921
      The reparative techniques were performed with emphasis on principles originally described by Carpentier
      • Deloche A
      • Jebara VA
      • Relland JYM
      • et al.
      Valve repair with Carpentier techniques: the second decade.
      and Duran
      • Duran CG
      • Revuelta JM
      • Gaite L
      • Alonso C
      • Fleitas MG.
      Stability of mitral reconstruction surgery at 10-12 years for predominantly rheumatic valvular disease.
      with certain modifications.
      • Cohn LH
      • DiSesa VJ
      • Couper GS
      • et al.
      Mitral valve repair for myxomatous degeneration and prolapse of the mitral valve.
      The most common operation was resection of the prolapsed midscallop of the posterior leaflet and placement of a flexible annuloplasty ring. Correction of the anterior leaflet by limited resection, chordal transfer from posterior to anterior leaflet, and, in these cases, replacement of anterior leaflet chordae by polytetrafluoroethylene sutures
      • Frater RWM
      • Vetter HO
      • Zussa C
      • Dahm M.
      Chordal replacement in mitral valve repair.
      *Gore-Tex suture, registered trademark of W. L. Gore & Associates, Inc., Newark, Del.
      were also used. Commissuroplasty was used primarily for posterior commissural prolapse. In two patients extensive posterior leaflet calcification was removed in its entirety by the technique of Carpentier
      • El Asmar B
      • Acker M
      • Couetil JP
      • et al.
      Mitral valve repair in the extensively calcified mitral valve annulus.
      ; the reattachment of the leaflet to the anulus and the repair of the posterior leaflet were carried out as usual. Annuloplasty techniques varied: no annuloplasty ring was used in 64 patients (29%), the Carpentier-Edwards ring (Baxter Healthcare Corp., Edwards Division, Santa Ana, Calif.) was used in 44 patients (20%), and the Duran ring (Medtronic, Inc., Minneapolis, Minn.) was used in 111 patients (51%).
      Intraoperative transesophageal Doppler echocardiography has been routinely used in the past 3 years, and every patient had a postoperative Doppler echocardiogram before leaving the hospital at 4 to 7 days. Patients in atrial fibrillation underwent anticoagulation therapy at approximately 50% above control levels before leaving the hospital. Patients in sinus rhythm, regardless of the type of annuloplasty treatment, were given 320 mg of aspirin a day and had no other anticoagulation regimen.

      Follow-up

      All patients were contacted and followed up by the clinical research group of the Division of Cardiac Surgery beginning in the winter of 1993. Operative death was defined as any death occurring within 30 days or during the initial hospitalization. Late deaths, thromboembolic complications, infectious valve dysfunction, structural valve degeneration, and reoperations were reviewed, and Kaplan-Meier survival curves were constructed. Univariate analyses included done with χ2 or Fisher’s exact test. Early and late survival among groups were compared by the log-rank test.
      Combinations of variables, including age, concomitant coronary bypass, functional class, and rhythm, were tested simultaneously by multivariate analysis for survival. Similarly, the variables of anterior leaflet resection and presence or absence of annuloplasty ring were evaluated for structural valve degeneration with the Cox proportional-hazards model.
      • Cox DR.
      Regression models and life tables.

      RESULTS

      There were five operative deaths in the 219 (2.3%) patients who underwent operation on for mitral regurgitation with reparative techniques. All deaths were due to noncardiac causes: respiratory failure (n = 2), ischemic bowel (n = 1), aortic dissection (n = 1), and anticoagulant hemorrhage (n = 1). Four of the five deaths occurred in patients who were over the age of 70; only one death occurred in the 141 patients under the age of 70 undergoing mitral valve repair (Table IV). Patients who had concomitant coronary bypass did not appear to have a significantly increased operative risk.
      Table IVMitral repair of floppy valve: mortality
      Operative mortality
       Overall5/219 (2.3%)
       <70 yr1/141 (0.7%)
       ≥70 yr4/78 (5.1%)p = NS
      With CABG1/63 (1.6%)
      Without CABG4/156 (2.6%)p = NS
      Late mortality
       Noncardiac5
        Suicide2
        Brain stem1
        Hepatic failure1
        Septicemia1
       Cardiac6
        CHF3
        Arrhythmia2
        MI1
       Total11/219 (5%)
      NS, Not significant; CABG, coronary artery bypassgraft; CHF, chronic heartfailure;MI, mitralinsufficiency.
      Figure thumbnail gr1
      Fig. 1Actuarial survival curves showing overall mortality.

      Thromboembolic complications

      Figure thumbnail gr2a
      Fig. 2Actuarial curve for freedom from thromboembolism (A), and actuarial curves for thromboembolic risk, separated by postop rhythm, and atrial fibrillation or sinus rhythm (B).
      Figure thumbnail gr2b
      Fig. 2Actuarial curve for freedom from thromboembolism (A), and actuarial curves for thromboembolic risk, separated by postop rhythm, and atrial fibrillation or sinus rhythm (B).

      Infectious valve degeneration

      Infectious valve dysfunction occurred in two instances in the late postoperative period with a probability of freedom from infectious valve degeneration of 97% ± 2% at 5 years (Table V).
      Table VMitral repair of floppy valve: 5-year freedom from morbidity
      TE94% ± 3%
      IVD97% ± 2%
      SVD83% ± 4%
      REOP83% ± 4%
      A/C Hem98% ± 1%
      Total74% ± 5%
      TE, Thromboembolism; IVD, infectious valve degeneration; SVD, structural valve degeneration; REOP, reoperation; A/C Hem, anticoagulant-related hemorrhage.

      Postoperative functional classification

      The postoperative functional classification dramatically improved, with 180 patients in functional classifications I and II and only three patients in functional classifications III and IV (Table II). Operative deaths, postoperative deaths, and reoperations were excluded from functional class analysis; thus, data on only 183 patients was included in this analysis.

      Structural valve degeneration and reoperation

      Figure thumbnail gr3a
      Fig. 3Actuarial curve for overall structural valve degeneration (A), and actuarial curves for SVD comparing repairs with an annuloplasty ring versus no ring (B).
      Figure thumbnail gr3b
      Fig. 3Actuarial curve for overall structural valve degeneration (A), and actuarial curves for SVD comparing repairs with an annuloplasty ring versus no ring (B).
      Figure thumbnail gr4
      Fig. 4Actuarial curve of freedom from all morbidity.

      DISCUSSION

      Mitral valve regurgitation caused by myxomatous degeneration can be repaired in the majority of cases.
      • Olson LJ
      • Subramanian R
      • Ackerman DM
      • Orszulak TA
      • Edwards WD.
      Surgical pathology of the mitral valve: a study of 712 cases spanning 21 years.
      • Deloche A
      • Jebara VA
      • Relland JYM
      • et al.
      Valve repair with Carpentier techniques: the second decade.
      • Duran CG
      • Revuelta JM
      • Gaite L
      • Alonso C
      • Fleitas MG.
      Stability of mitral reconstruction surgery at 10-12 years for predominantly rheumatic valvular disease.
      • Cohn LH
      • DiSesa VJ
      • Couper GS
      • et al.
      Mitral valve repair for myxomatous degeneration and prolapse of the mitral valve.
      • Frater RWM
      • Vetter HO
      • Zussa C
      • Dahm M.
      Chordal replacement in mitral valve repair.
      • El Asmar B
      • Acker M
      • Couetil JP
      • et al.
      Mitral valve repair in the extensively calcified mitral valve annulus.
      This study, like others that have been recently reported,
      • Cosgrove DM
      • Stewart WJ.
      Mitral valvuloplasty.
      • David TE
      • Armstrong S
      • Sun Z
      • Daniel L.
      Late results of mitral valve repair for mitral regurgitation due to degenerative disease.
      has indicated that even in complex repairs involving both the anterior and the posterior leaflet, there can be a reasonable expectation of a competent valve with long-lasting durability; these findings confirm the pioneering work of both Carpentier and Duran, who were the first to show that, in the myxomatous degenerated valve, expected long-term durability would be the rule rather than the exception. Indeed, Carpentier has shown in his seminal work that the probability of valve failure at 12 years after repair of mitral regurgitation from this cause is less than 5%
      • Deloche A
      • Jebara VA
      • Relland JYM
      • et al.
      Valve repair with Carpentier techniques: the second decade.
      ; similar results have been reported by Duran and associates.
      • Duran CG
      • Revuelta JM
      • Gaite L
      • Alonso C
      • Fleitas MG.
      Stability of mitral reconstruction surgery at 10-12 years for predominantly rheumatic valvular disease.
      Early in our experience, posterior leaflet repairs were performed with resection of the middle scallop with or without placement of an annuloplasty ring. As more experience has been gained, however, repair of the more complex lesions involving both anterior and posterior lesions have become commonplace. Like David and associates,
      • David TE
      • Armstrong S
      • Sun Z
      • Daniel L.
      Late results of mitral valve repair for mitral regurgitation due to degenerative disease.
      who recently reported their experience, we reported that structural valve degeneration after repair occurred most often when an anterior leaflet resection was required or if an annuloplasty ring had not been placed. Yacoub and associates
      • Yacoub M
      • Halim M
      • Radley-Smith R
      • et al.
      Surgical treatment of mitral regurgitation caused by floppy valves: repair versus replacement.
      have emphasized that mitral valve repairs need not include annuloplasty rings. In many cases this is possible, although the anulus of the myxomatous degenerated valve, particularly one that is long standing, may be deformed to such a degree that the reshaping of the anulus by placement of the mattress sutures around the posterior anulus and then placement of the annuloplasty becomes important. The stabilization of the posterior anulus with a ring or some type of support has been considered important for the stabilization of the posterior leaflet and create a buttress against which the anterior leaflet can open and close. There exists continuing discussion about the ideal annuloplasty ring, either the rigid Carpentier-Edwards ring or the more flexible Duran ring. There is some evidence that the softer flexible ring is more beneficial to postoperative left ventricular performance.
      • David TE
      • Komeda M
      • Pollick C
      • Burns RJ.
      Mitral valve annuloplasty: the effect of the type on left ventricular function.
      We have systematically used the more pliable and flexible Duran ring in our recent experience because of its better adaptability, although no differences in outcomes were noted between the two rings. We believe that the prevalence of systolic anterior motion of the mitral valve is less after the use of this device
      • Kenny J
      • Cohn LH
      • Shemin R
      • Collins Jr, JJ
      • Plappert M
      • St. John Sutton MG.
      Doppler echocardiographic evaluation of ring mitral valvuloplasty for pure mitral regurgitation.
      compared with the Carpentier-Edwards ring,
      • Grossi EA
      • Galloway AC
      • Parish MA
      • et al.
      Experience with twenty-eight cases of systolic anterior motion after mitral valve reconstruction by the Carpentier technique.
      • Mihaileanu S
      • Marino JP
      • Chauvaud S
      • et al.
      Left ventricular outflow obstruction after mitral valve repair (Carpentier's technique): proposed mechanisms of disease.
      unless, as Carpentier suggests, a sliding posterior valvuloplasty is carried out by annular preshortening (personal communication, 1989). A number of surgeons have now begun to use only posterior annular support: Denton Cooley (personal communication, 1992) and Delos Cosgrove (personal communication, 1993) believe that stabilization of the posterior anulus is the most critical factor in mitral valve repair.
      Operative survival in this series included a large percentage of patients over 70 years of age, was 97.7%. This is a “pure” series of mitral regurgitation without any other valve lesion, and this operative risk, particularly in a large group of patients with both coronary artery disease and a high percentage of patients over 70 years of age, compares favorably with other series of valve repairs and replacements.
      • Scott ML
      • Stowe CL
      • Nunnally LC
      • et al.
      Mitral valve reconstruction in the elderly population.
      Much has been written about the differences in mitral valve repair and mitral valve replacement for mitral regurgitation,
      • Angell WW
      • Oury JH
      • Shah P.
      A comparison of replacement and reconstruction in patients with mitral regurgitation.
      • Galloway AC
      • Colvin SB
      • Baumann FG
      • et al.
      A comparison of mitral valve reconstruction with mitral valve replacement: intermediate-term results.
      • Perier P
      • Deloche A
      • Chauvaud S
      • et al.
      Comparative evaluation of mitral valve repair and replacement with Starr, Björk, and porcine valve prostheses.
      suggesting early and late results are far worse after replacement. We recently reported no difference in the operative mortality between mitral valve replacement and mitral valve repair when, with the former, we preserved the posterior leaflet and chordae papillary muscle continuity.
      • Cohn LH
      • Couper GS
      • Kinchla NM
      • Collins JJ.
      Decreased operative risk of surgical treatment of mitral regurgitation with or without coronary artery disease.
      Other current reports have also documented that operative survival is equal in repair and replacement.
      • Craver JM
      • Cohen C
      • Weintraub WL.
      Case-matched comparison of mitral valve replacement and repair.
      Preservation of all the papillary muscles and chordae with mitral valve repair are important for not only better immediate left ventricular function, but data suggests that improvement in late survival, as well as a reduction in thromboemboli, may be the result of improved postoperative cardiac function. Although very few studies have documented the improvements in function after repair and replacement leaving all the papillary muscles in place, David and Ho
      • David TE
      • Ho WC.
      The effect of preservation of chordae tendineae on mitral valve replacement for postinfarction mitral regurgitation.
      and Rozich and associates
      • Rozich JD
      • Carabello BA
      • Usher BW
      • Kratz JM
      • Bell AE
      • Zile MR.
      Mitral valve replacement with and without chordal preservation in patients with chronic mitral regurgitation: mechanisms for differences in postoperative ejection performance.
      have shown that ejection fraction and other more sensitive indexes of left ventricular function were better preserved when the papillary muscles were left in continuity. However, it does appear that patients after mitral valve repair for mitral regurgitation seem to have a better long-term survival.
      • Rankin JS
      • Feneley MP
      • St. J. Hickey M
      • et al.
      A clinical comparison of mitral valve repair versus valve replacement in ischemic mitral regurgitation.
      • Sand ME
      • Naftel DC
      • Blackstone EH
      • Kirklin JW
      • Karp RB.
      A comparison of repair and replacement for mitral valve incompetence.
      One should be careful, however, in comparing long-term survival of nonmatched and nonprospectively randomized patients, but the data suggest that survival and function are better because of the preservation of papillary muscles and chordae. In cases of chronic mitral regurgitation, preservation of this anatomic relationship appears to be more important than closure of the “pop-off” valve for the left ventricle previously thought to be the more important focus of the repair.
      • Kirklin JW.
      Replacement of the mitral valve for mitral incompetence.
      The prevalence of thromboembolism has been exceedingly low after mitral valve repair, even though at least one third of our patients are in chronic atrial fibrillation during anticoagulation therapy, a finding documented by others.
      • Angell WW
      • Oury JH
      • Shah P.
      A comparison of replacement and reconstruction in patients with mitral regurgitation.
      • Galloway AC
      • Colvin SB
      • Baumann FG
      • et al.
      A comparison of mitral valve reconstruction with mitral valve replacement: intermediate-term results.
      • Perier P
      • Deloche A
      • Chauvaud S
      • et al.
      Comparative evaluation of mitral valve repair and replacement with Starr, Björk, and porcine valve prostheses.
      The minimal presence of prosthetic material and better hemodynamics with the repaired valve are obvious advantages over mitral valve replacement. David and associates
      • David TE
      • Armstrong S
      • Sun Z
      • Daniel L.
      Late results of mitral valve repair for mitral regurgitation due to degenerative disease.
      in a recent paper reported a higher prevalence of thromboemboli despite an intense perioperative anticoagulation regimen. These results may reflect the fact that this was not a pure series of patients with mitral regurgitation, but included other valve operations.
      In summary, mitral valve repair for mitral regurgitation as a result of myxomatous degeneration of the mitral valve is feasible in a large percentage of patients and is associated with a low mortality and morbidity. Late results indicate that there is excellent survival, and a low prevalence of thromboembolic and infectious complications. Structural valve degeneration remains the major form of morbidity after this operation, but as experience with these procedures increases, the prevalence of structural valve degeneration decreases. The study also confirms that some form of annuloplasty ring appears to be important in the overall mitral valve reconstructive process.

      DISCUSSION

      Dr. Lawrence I. Bonchek (Lancaster, Pa.)

      I would like to comment on structural deterioration in flexible rings versus that in rigid rings. It appeared from your abstract that deterioration occurred more often in patients who had received rigid rings than it did in those who had received flexible rings.
      In our own experience with mitral valve repair, which is now approximately 200 cases, we found the opposite to be true regarding recurrences. We have put in only about a half dozen flexible rings and have had two recurrences in those patients. I believe the results depend on what one is most familiar with and most comfortable with; I noted that in your series you used the flexible ring more often, and I suspect you were better with it.
      Because there are so many different methods of repairing mitral valves successfully, any surgeon who is comfortable with a rigid ring or with a flexible ring ought not be too easily swayed and ought to continue using what works for him or her.

      Dr. James H. Oury (Missoula, Mont.)

      Our own series, another American series, substantiates your findings. This series covers 1980 to 1992, with a total of 221 patients undergoing repair. This series is heavily weighted toward either ischemic or, as in the case of your report, degenerative disease, which accounted for 98 cases (45%) of the overall series; a small number of cases of rheumatic disease. One death occurred in this group, and we performed seven reoperations, which are an inherent part of any series of mitral valve repair. The average patient age was 67 years, with a range of 21 to 85 years, which lends some credence to using a ring annuloplasty of some type as a reinforcement for these repairs. We deal with an older age group in the United States, and I think that is an important point.
      Our first patient underwent operation in 1974; postoperative systolic angiography showed no mitral regurgitation in the patient, who had undergone annuloplasty with a Carpentier-Edwards ring (Baxter).
      This patient was alive and doing very well 19 years after her mitral valve repair. Since 1976, we have used the flexible ring exclusively. We have had no occurrence of systolic anterior motion with this particular ring that we have identified. I would ask you to comment on the prevalence of systolic anterior motion in your series and if you think there is any difference between the flexible and the rigid ring in that regard.

      Dr. Cohn

      I think the great contribution in this area, thanks to Alain Carpentier and Carlos Duran, is the concept of a ring annuloplasty. Until that was done, there was really no standardized approach to these operations. After these rings were introduced, the whole concept of mitral repair, which has become an exceedingly complex series of operations, was built on that sort of framework. When you have a standardized way to do things, it is extraordinarily helpful.
      I have no particular quarrel with Dr. Bonchek in regard to what type of ring is used. I think one does what works best in one's own clinic, and, therefore, we have used Duran rings in a large number of cases. We do believe, for us at least, either a posterior leaflet type of stabilization or some form of annuloplasty ring is helpful.
      The problem of recurrence is one that I do not think you can predict. We have had recurrences in patients with a small anulus, where the tissue has been relatively friable, but we have had most recurrences when we did not use a ring, where the anulus was distorted and needed to be reshaped by the ring, which I think is important. Now, I do not know how to predict recurrence, but I find that ring annuloplasty is much more predictable, particularly if you are helping residents and fellows to learn these techniques, to use this methodology.
      Again, to Dr. Bonchek, we analyzed our statistics and added 20 cases to the numbers, and no statistical difference was found between either type of ring with regard to structural valve degeneration.
      To Dr. Oury, in all of these patients, by having a postoperative echocardiogram before they were discharged from the hospital, we did not observe a single case of systolic anterior motion.

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