Toward a New Paradigm for the Reconstruction of Posterior Leaflet Prolapse: Midterm Results of the “Respect Rather Than Resect” Approach

Background The aim of mitral valve reconstruction is restoration of good coaptation surface. Resection of the prolapsed area has been the accepted technique to repair prolapse of the posterior leaflet (PPL). However, as leaflet tissue is the basic component of coaptation surface, the logical corrective approach was thought to be the transformation of the posterior leaflet into a smooth vertical buttress without resection, the “respect rather than resect” approach. Methods Between 1994 and 2004, 225 patients underwent a PPL repair for severe mitral regurgitation with the respect rather than resect approach, in which the prolapse was corrected with artificial chordae. In 193 patients, the prolapse was limited to the posterior leaflet; in the remaining 32 patients, both leaflets were involved. All patients received ring annuloplasty. Associated procedures included myocardial revascularization (21 patients) and tricuspid repair (19 patients). Patient demographics were as follows: mean age, 60.7 ± 12.9 years; male, 150 (67%); asymptomatic, 102 (45%). Results Three patients died postoperatively (1.3%). Survival at 10 years (88% ± 6%) was similar to expected survival rate (97% ± 2% for asymptomatic patients and 82% ± 10% for symptomatic patients (p < 0.005)). Ten patients were reoperated on, for a freedom from reoperation rate of 93% ± 3% at 10 years. At echocardiographic follow-up, 172 patients of 195 (88%) showed mitral regurgitation of 1 or less; and 195 of 203 patients (96%) were in New York Heart Association functional class I or II. Conclusions The respect rather than resect approach is safe, effective, and durable, and increases technical repair possibilities. Surgical strategy focuses on restoration of surface coaptation instead of location and extent of leaflet resection.