Mitral Valve Repair

for Thoracic Surgery, it was 3 decades after he had successfully split the fused mitral commissures of a 19-year-old girl with his index finger through a controlled incision to the left atrial appendage.It took another 60 years for cardiac surgery to achieve the safe, reproducible, and predictably durable operative outcomes observed in our era of modern surgery.The leap from sporadic digital valve exploration, often fraught with devastating complications, to quaternary specialist centers with dedicated heart teams has been remarkable for allowing the adjudication of patient-and procedure-related risk, which is translated to a care plan adjusted to individual patient characteristics.In the case of complex degenerative mitral valve disease, careful patient selection and a lesion-specific operative approach can achieve near 100% successful repair rates (2), with excellent long-term outcomes, due mainly to judicious preoperative screening and available teams specializing in cardiac anesthesia, intensive care, heart failure, interventional cardiology, and advanced, multimodality imaging (3).In this issue of JACC: Case Reports, Fabozzo et al. (4) present a case of what initially appeared to be a routine elective repair of degenerative mitral prolapse (if "routine" could describe the appropriate nuance of diversity and unique complexity inherent to degenerative valve pathology; it does not) (4).As such, the vignette describes a young (49 years of age), asymptomatic man recently made aware during a routine physical examination of an incidental, previously unknown systolic heart murmur, subsequently referred to the investigators' service for surgical consultation and further management.The vignette proceeds to report the subsequent echocardiographic evaluation of the mitral valve and left ventricle, which was pertinent for severe mitral regurgitation (MR), left ventricular dilatation and an ejection fraction of 65%, and an anomalous origin and trajectory of the left circumflex coronary artery (LCx), the latter emerging as the key player in the clinical case reported herein.Although the first synoptic lines of the vignette aim to clearly frame the context of the case: an asymptomatic young man with severe MR, leaflet prolapse, a dilated left ventricle, preserved ejection fraction, and the twist (anomalous coronary anatomy), it is important to note that what the investigators are attempting, perhaps fleetingly, is to describe the patient's indication(s) for mitral surgery according to current recommendations for the diagnosis and management of mitral valve disease (5).Although the focus (of this case report) is on the role of the coronary anomaly in the operative planning and surgical strategy, a clear description of the reason to contemplate surgery, as opposed to the alternative of active surveillance, is necessary to educate but also limit any attempt of speculative interpretation by the