Klautz, R.J.M.

Palmen, M.

Tomsic, A.

Interactive Cardiovascular and Thoracic Surgery

NARCIS 

eComment. Posterior mitral valve leaflet prolapse: one term, several different meanings

Anton Tomsic

Robert J M Klautz

Meindert Palmen

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Leiden University Scholary Publications

eComment. Posterior mitral valve leaflet prolapse: one term, several differentmeaningsAuthors: Anton Tomsic, Robert J.M. Klautz and Meindert PalmenDepartment of Cardiothoracic Surgery, Leiden University Medical Center, Albinusdreef 2,2333 ZA, Leiden, Netherlandsdoi: 10.1093/icvts/ivx360VC The Author(s) 2018. Published by Oxford University Press on behalf of theEuropean Association for Cardio-Thoracic Surgery. All rights reserved.With great interest we read the study by Jahren et al. who compare the effect ofvarious repair techniques on mitral valve function and gradients in an ex vivo por-cine model of acute mitral regurgitation caused by resection of marginal chordae ofthe P2 segment of the posterior mitral valve leaflet (PMVL) [1]. The authors con-clude that neochordoplasty with or without ring annuloplasty achieved lower dia-stolic transvalvular pressure gradients compared with edge-to-edge repair or leafletresection. The study is of particular interest in the field of reconstructive mitral valvesurgery and the authors are to be congratulated on their results.Their conclusions however need to be interpreted by taking the limitations ofthe study into account. In patients with PMVL prolapse, the aim of mitral valve re-pair is to (i) resolve any leaflet prolapse, (ii) address excessive leaflet tissue in heightand (iii) address excessive tissue in width. The indication for leaflet resection has re-cently shifted to addressing excessive leaflet tissue while leaflet prolapse is increas-ingly being addressed with chordal replacement alone. In a model of acute mitralregurgitation, no excessive tissue is present and we agree with the authors thatchordal replacement with annuloplasty presents the most appropriate repair tech-nique in this setting. As the authors performed triangular tissue resection in absenceof any excessive tissue, the inevitable result is excessive tissue resection with exces-sive shortening of the free margin of the PMVL. This will result in limited diastolicmotion of the PMVL and is reflected in their study by an unwanted rise in the dia-stolic transvalvular pressure gradients. Their results however do not hold true forcases of PMVL prolapse where some degree of excessive tissue is present due tomyxomatous degeneration. In such cases, tissue resection should be made with re-spect to PMVL motion and excessive resection should be avoided [2]. Any excessivetissue that will remain unaddressed (it should be noted that shortening neochordscan address excessive tissue in height only) will result in excessive leaflet motion(billowing). This leads to increased stress on the subvalvular apparatus that couldprove to be detrimental for repair stability and therefore durability in the long-term. Of particular interest is the profound effect of the edge-to-edge repair tech-nique on the transvalvular mitral valve gradients. The problem of functional mitralvalve stenosis following valve repair has just recently come to light and remains in-sufficiently explored [3]. As the edge-to-edge technique impairs normal leaflet mo-tion, the effect might be even more profound under stress. The results of the studyby Jahren et al. somehow question the appropriateness of the edge-to-edge tech-nique in patients with small indexed mitral valve annuli.In conclusion, the study of Jahren et al. provides new interesting knowledge onthe effect of various repair techniques on mitral valve function and highlights thefact that excessive tissue resection should be avoided.REFERENCES[1] Jahren SE, Hurni S, Heinisch PP, Winkler B, Obrist D, Carrel T et al.Transvalvular pressure gradients for different methods of mitral valve repair:only neochordoplasty achieves native valve gradients. Interact CardioVascThorac Surg 2018;26:248–56.[2] Dreyfus GD, Corbi P, Rubin S, Aubert S. Posterior leaflet preservation in mitralvalve prolapse: a new approach to mitral repair. J Heart Valve Dis 2006;15:528–30.[3] Mesana TG, Lam B-K, Chan V, Chen K, Ruel M, Chan K. Clinical evaluation offunctional mitral stenosis after mitral valve repair for degenerative disease:potential effect on surgical strategy. J Thorac Cardiovasc Surg 2013;146:1418–23; discussion 1423-5.256 S.E. Jahren et al. / Interactive CardioVascular and Thoracic SurgeryDownloaded from https://academic.oup.com/icvts/article-abstract/26/2/256/4817695 by Jacob Heeren user on 19 July 2019

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eComment. Posterior mitral valve leaflet prolapse: one term, several different meanings

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