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A “Repair All Comers” Strategy in Barlow Mitral Valve Prolapse: Are all Complex Degenerative Valves Repairable?

Javier G. Castillo, Anelechi C. Anyanwu, David H. Adams.
The Mount Sinai Medical Center, New York, NY, USA.

Barlow mitral valve prolapse presents the most complex sub-group of lesions in degenerative mitral regurgitation (MR). Multi-segmental prolapse, chordal elongation and rupture, giant excess leaflet tissue and annular size, and annular/sub-valvular calcification often complicate repair. Mitral valve replacement is more prevalent in this subgroup because surgeons are often concerned about safety, feasibility, and durability of complex valve repair. We sought to characterize the efficacy of a “repair all comers” strategy in a consecutive series of patients with Barlow’s valve disease.
From 1/2002 to 12/2010, 245 consecutive patients [mean age 53 years (range 21-90), 34.5% female, mean LVEF 55±8%] underwent surgical intervention for MR secondary to Barlow’s disease, defined as giant excess leaflet tissue in combination with large annular size (≥36mm annuloplasty). All patients presented with severe regurgitation (61 patients (24.9%) were asymptomatic) and leaflet prolapse [anterior (n=5,2%); posterior (n=151,63%); bileaflet (n=89,35%)]. Multi-segment prolapse (n= 173,71%) and annular calcification (n=72,29%) were common. A lesion based repair approach was applied utilizing conventional repair techniques.
Mitral valve repair was successfully completed in all patients. Most frequently employed repair techniques were posterior leaflet resection ± sliding plasty (n=186,75.9%), anterior leaflet resection (n=17,7.2%), chordal transfer or replacement with PTFE (n=129,52.6%). All patients received a concomitant annuloplasty with a ring size 36mm (n=106,43%), 38mm (n=74,30%), or 40mm (n=65, 23%). There was no hospital mortality and the stroke rate was 0.8% (n=2). Kaplan Meier survival at 3 and 5 years was 99% and 97.9% respectively. Early follow-up transthoracic echocardiography [mean follow-up 269 days (range 5-1991 days)] revealed 98.1% freedom from ≥2+ MR (84% of patients had none or trace MR at last follow-up).
By systematically applying a “repair all comers” strategy we have achieved successful repair of all Barlow valve’s with stable early results and no obvious incremental risk. We believe that flexibility in approach (combination of resection and non-resection methods), and tailoring of technique according to specific pathology and lesions, is the key to achieving a 100% repair rate for Barlow valves - a target which is now particularly relevant in the context of expanding indications for mitral surgery in asymptomatic patients.
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