What is a good mitral valve repair?

Central MessageA “good” mitral valve repair should have minimal residual mitral regurgitation. Surgeons should consider a second pump run in selected patients with mild residual mitral regurgitation after MV repair.See Article page XXX.Although randomized, controlled trials are lacking, cardiac surgeons and cardiologists agree that mitral valve repair is generally preferred to mitral valve replacement in patients with mitral regurgitation (MR) caused by degenerative mitral valve disease (ie, mitral valve prolapse). A good mitral valve repair procedure optimizes 3 critical elements; safety, procedural success, and the least-invasive approach that secures both safety and success. In their report detailing results in 858 patients undergoing robotic mitral valve surgery, Chen and colleagues1Chen Q. Roach A. Trento A. Rowe G. Gill G. Peiris A. et al.Robotic degenerative mitral repair: factors associated with intraoperative revision and impact of mild residual regurgitation.J Thorac Cardiovasc Surg. August 5, 2022; ([Epub ahead of print])Abstract Full Text PDF Scopus (1) Google Scholar provide data that informs expectations in each of these domains.Procedural safety cannot be compromised. Specifically, surgeons must guard against choosing a less-invasive approach in instances when it is less safe. In this regard, patient selection is key, and Chen and colleagues, with an operative mortality of 0.1%, clearly employ excellent judgment in choosing patients for robotic mitral valve surgery. Regardless of the surgical approach, a good mitral valve repair should be accompanied by an operative risk well less than 1%, a mark that has been achieved by several experienced centers.2Gillinov A.M. Mihaljevic T. Javadikasgari H. Suri R.M. Mick S.L. Navia J.L. et al.Early results of robotically assisted mitral valve surgery: analysis of the first 1,000 cases.J Thorac Cardiovasc Surg. 2018; 155: 82-91.e2Abstract Full Text Full Text PDF PubMed Scopus (84) Google Scholar, 3David T.E. David C.M. Tsang W. Lafreniere-Roula M. Manlhiot C. Long-term results of mitral valve repair for regurgitation due to leaflet prolapse.J Am Coll Cardiol. 2019; 74: 1044-1053Crossref PubMed Scopus (83) Google Scholar, 4Castillo J.G. Anyanwu A.C. Fuster V. Adams D.H. A near 100% repair rate for mitral valve prolapse is achievable in a reference center: implications for future guidelines.J Thorac Cardiovasc Surg. 2012; 144: 308-312Abstract Full Text Full Text PDF PubMed Scopus (199) Google ScholarWhile no reasonable practitioner would argue that increased operative mortality is acceptable, such agreement does not exist when considering the acceptable degree of residual MR at the conclusion of a mitral valve repair. With the advent of transcatheter therapies and the launch of trials comparing surgical repair with transcatheter repair, the question of the acceptable degree of residual, postprocedural MR has received considerable attention. Traditionally, surgeons have strived to perform repairs that result in less than mild, or, at most, mild residual MR. Absent extenuating circumstances, surgeons are rarely satisfied with leaving moderate or greater residual MR. Chen and colleagues confirm previous studies with their finding that patients left with mild residual MR are more likely to develop greater degrees of MR in follow-up.5Suri R.M. Clavel M.A. Schaff H.V. Michelena H.I. Huebner M. Nishimura R.A. et al.Effect of recurrent mitral regurgitation following degenerative mitral valve repair: long-term analysis of competing outcomes.J Am Coll Cardiol. 2016; 67: 488-498Crossref PubMed Scopus (145) Google Scholar,6Imielski B. Malaisrie S.C. Pham D.T. Kruse J. Andrei A.C. Liu M. et al.The impact of intraoperative residual mild regurgitation after repair of degenerative mitral regurgitation.J Thorac Cardiovasc Surg. 2019; 161: 1215-1224Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar This, of course, makes perfect sense. In addition, their data suggest that mild residual MR jeopardizes subsequent survival and freedom from mitral reintervention. This finding of reduced survival in those with mild residual MR must be considered hypothesis-generating, as previous studies have not confirmed this relationship.6Imielski B. Malaisrie S.C. Pham D.T. Kruse J. Andrei A.C. Liu M. et al.The impact of intraoperative residual mild regurgitation after repair of degenerative mitral regurgitation.J Thorac Cardiovasc Surg. 2019; 161: 1215-1224Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar Nonetheless, there are no data to suggest that having more residual MR is in any way good for a patient, and it stands to reason that less MR is better. Therefore, if a postrepair, intraoperative echocardiogram demonstrates mild MR and a mechanism that is clear and easily correctable (eg, residual prolapse, a recognizable cleft, systolic anterior motion), the surgeon should consider a second pump run to improve the result.Safety and effectiveness—that is, quality—are the primary considerations when performing mitral valve repair in patients with degenerative disease; choice of chest wall incision is predicated on optimizing these 2 factors. With their excellent results, Chen and colleagues demonstrate the characteristics of high-quality mitral valve repair surgery. To best serve our patients' interests, we must not compromise on these measures of quality. A “good” mitral valve repair should have minimal residual mitral regurgitation. Surgeons should consider a second pump run in selected patients with mild residual mitral regurgitation after MV repair. A “good” mitral valve repair should have minimal residual mitral regurgitation. Surgeons should consider a second pump run in selected patients with mild residual mitral regurgitation after MV repair. See Article page XXX. See Article page XXX. Although randomized, controlled trials are lacking, cardiac surgeons and cardiologists agree that mitral valve repair is generally preferred to mitral valve replacement in patients with mitral regurgitation (MR) caused by degenerative mitral valve disease (ie, mitral valve prolapse). A good mitral valve repair procedure optimizes 3 critical elements; safety, procedural success, and the least-invasive approach that secures both safety and success. In their report detailing results in 858 patients undergoing robotic mitral valve surgery, Chen and colleagues1Chen Q. Roach A. Trento A. Rowe G. Gill G. Peiris A. et al.Robotic degenerative mitral repair: factors associated with intraoperative revision and impact of mild residual regurgitation.J Thorac Cardiovasc Surg. August 5, 2022; ([Epub ahead of print])Abstract Full Text PDF Scopus (1) Google Scholar provide data that informs expectations in each of these domains. Procedural safety cannot be compromised. Specifically, surgeons must guard against choosing a less-invasive approach in instances when it is less safe. In this regard, patient selection is key, and Chen and colleagues, with an operative mortality of 0.1%, clearly employ excellent judgment in choosing patients for robotic mitral valve surgery. Regardless of the surgical approach, a good mitral valve repair should be accompanied by an operative risk well less than 1%, a mark that has been achieved by several experienced centers.2Gillinov A.M. Mihaljevic T. Javadikasgari H. Suri R.M. Mick S.L. Navia J.L. et al.Early results of robotically assisted mitral valve surgery: analysis of the first 1,000 cases.J Thorac Cardiovasc Surg. 2018; 155: 82-91.e2Abstract Full Text Full Text PDF PubMed Scopus (84) Google Scholar, 3David T.E. David C.M. Tsang W. Lafreniere-Roula M. Manlhiot C. Long-term results of mitral valve repair for regurgitation due to leaflet prolapse.J Am Coll Cardiol. 2019; 74: 1044-1053Crossref PubMed Scopus (83) Google Scholar, 4Castillo J.G. Anyanwu A.C. Fuster V. Adams D.H. A near 100% repair rate for mitral valve prolapse is achievable in a reference center: implications for future guidelines.J Thorac Cardiovasc Surg. 2012; 144: 308-312Abstract Full Text Full Text PDF PubMed Scopus (199) Google Scholar While no reasonable practitioner would argue that increased operative mortality is acceptable, such agreement does not exist when considering the acceptable degree of residual MR at the conclusion of a mitral valve repair. With the advent of transcatheter therapies and the launch of trials comparing surgical repair with transcatheter repair, the question of the acceptable degree of residual, postprocedural MR has received considerable attention. Traditionally, surgeons have strived to perform repairs that result in less than mild, or, at most, mild residual MR. Absent extenuating circumstances, surgeons are rarely satisfied with leaving moderate or greater residual MR. Chen and colleagues confirm previous studies with their finding that patients left with mild residual MR are more likely to develop greater degrees of MR in follow-up.5Suri R.M. Clavel M.A. Schaff H.V. Michelena H.I. Huebner M. Nishimura R.A. et al.Effect of recurrent mitral regurgitation following degenerative mitral valve repair: long-term analysis of competing outcomes.J Am Coll Cardiol. 2016; 67: 488-498Crossref PubMed Scopus (145) Google Scholar,6Imielski B. Malaisrie S.C. Pham D.T. Kruse J. Andrei A.C. Liu M. et al.The impact of intraoperative residual mild regurgitation after repair of degenerative mitral regurgitation.J Thorac Cardiovasc Surg. 2019; 161: 1215-1224Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar This, of course, makes perfect sense. In addition, their data suggest that mild residual MR jeopardizes subsequent survival and freedom from mitral reintervention. This finding of reduced survival in those with mild residual MR must be considered hypothesis-generating, as previous studies have not confirmed this relationship.6Imielski B. Malaisrie S.C. Pham D.T. Kruse J. Andrei A.C. Liu M. et al.The impact of intraoperative residual mild regurgitation after repair of degenerative mitral regurgitation.J Thorac Cardiovasc Surg. 2019; 161: 1215-1224Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar Nonetheless, there are no data to suggest that having more residual MR is in any way good for a patient, and it stands to reason that less MR is better. Therefore, if a postrepair, intraoperative echocardiogram demonstrates mild MR and a mechanism that is clear and easily correctable (eg, residual prolapse, a recognizable cleft, systolic anterior motion), the surgeon should consider a second pump run to improve the result. Safety and effectiveness—that is, quality—are the primary considerations when performing mitral valve repair in patients with degenerative disease; choice of chest wall incision is predicated on optimizing these 2 factors. With their excellent results, Chen and colleagues demonstrate the characteristics of high-quality mitral valve repair surgery. To best serve our patients' interests, we must not compromise on these measures of quality. Robotic degenerative mitral repair: Factors associated with intraoperative revision and impact of mild residual regurgitationThe Journal of Thoracic and Cardiovascular SurgeryPreviewNational registry data show wide variability in degenerative mitral repair rates and infrequent use of intraoperative repair revision to eliminate residual mitral regurgitation (MR). The consequence of uncorrected mild residual MR is also not clear. We identified factors associated with intraoperative revision of degenerative mitral repair and evaluated long-term effects of intraoperative mild residual MR. Full-Text PDF