“Bow-Tie” mitral valve repair: An adjuvant technique for ischemic mitral regurgitation

Background. Current techniques of mitral valve repair rely on decreasing valve area to increase leaflet apposition, but fail to address subvalvular dysfunction. A novel repair has been introduced with partial left ventriculectomy, which apposes the anterior leaflet to a corresponding point on the posterior leaflet creating a double-orifice valve, with reported adequate control of mitral regurgitation. Methods. We started to use the “bow-tie” repair as an adjunct to posterior ring annuloplasty in cases in which mitral regurgitation was not adequately controlled by decreasing mitral valve area (n = 6), or when placement of an annuloplasty ring was impractical (n = 4). Mean follow-up was 336 days (range, 82 to 551 days) with no postoperative deaths. Results. Mitral regurgitation decreased from 3.6 ± 0.5 to 0.8 ± 0.4 (p< 0.0001), with a concomitant increase in ejection fraction from 33% ± 13% to 45% ± 11% (p = 0.0156) before hospital discharge. Mitral valve area, measured by pressure half-time, decreased from a mean of 2.5 ± 0.3 to 2.1 ± 0.3 cm2, with a mean transvalvular gradient of 4.5 ± 2.0 mm Hg. In patients whose mitral valve was repaired using the bow-tie alone, mitral regurgitation was reduced from 4+, to a trace to 1+. Postoperatively, mitral valve area increased from 1.9 to 2.5 cm2 during exercise, further supporting the concept that this technique preserves mitral valve annular function. Conclusions. These observations suggest that the bow-tie repair may offer advantages over conventional techniques of mitral valve repair and should be considered as an adjunct, especially in patients with impaired left ventricular function.