Complex mitral valve regurgitation: surgical evaluation, approach and repair techniques

The complexity of valve pathology in degenerative mitral valve disease has important implications in the operative approach and success of a reconstructive strategy. Originally described by Alain Carpentier’s pioneering concept of pathophysiologic triad, the type and burden of mitral valve lesions are specific to the etiology of valve disease. While fibroelastic deficiency for example, is likely limited to a single segment prolapse and a ruptured chord, Barlow’s valves lesions extend to involve multiple segments, clefts, chordae and the mitral annulus, requiring multiple repair techniques and an advanced level of surgical repair expertise. It is therefore important to assess disease etiology and lesion complexity during preoperative screening to plan operative approaches and anticipate operative complexity to maximize the opportunity for a successful mitral valve repair. While surgical repair techniques continue to evolve, over 95% of degenerative mitral valve lesions can be repaired successfully with targeted leaflet resection, leaflet resuspension using artificial chordae and/or native chordal transfer, and annular stabilization with a mitral annuloplasty device. With the exception of extensive annular/ leaflet calcification and some cases of significant fibrosis or inflammation which may prohibit a durable repair, most concomitant cleft, chordal, commissural and anterior leaflet pathology can be repaired successfully with a systematic lesion-specific approach, using a combination of techniques tailored to the individual valve pathology. The present article provides a state-of-the-art review of the systematic approach to complex degenerative mitral valve repair in our quaternary mitral valve reference center.