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Technological advances have recently enabled mitral valve repair to be performed using endovascular techniques and thus open the possibility of nonsurgical treatment of mitral valve disease. While balloon valvotomy has been applied to mitral stenosis for over 20 years, a number of devices aimed at correcting mitral regurgitation are currently in preclinical and clinical development. While some of these, such as edge-to-edge repair, are catheter adaptations of established surgical techniques, others represent true departures from the current surgical paradigms of correcting mitral regurgitation. This review will summarize the current status of percutaneous transcatheter techniques for mitral valve repair. Included are balloon mitral valvotomy, indirect annuloplasty, direct annuloplasty, ventricular shape change, and edge-to-edge repair. These techniques certainly represent a new interdisciplinary paradigm between cardiac surgery and interventional cardiology and may be the next frontier in minimally-invasive cardiac surgery.

Background: The optimal management of moderate (3+ on a scale of 0 to 4+) ischemic mitral regurgitation (MR) remains controversial. Some advocate CABG alone, whereas others favor concomitant mitral annuloplasty. To clarify the optimal management of these patients, we evaluated the early impact of isolated CABG on moderate ischemic MR., Methods and Results: Between January 1992 and August 1999, 136 patients (54% male, mean age 70.5 years, mean New York Heart Association class 2.7, mean ejection fraction 38.1%) with a preoperative diagnosis of moderate ischemic MR, without leaflet prolapse or pathology, underwent isolated CABG. Thirty-eight (28%) of 136 patients had intraoperative transesophageal echocardiography (TEE) before CABG, and 68 (50%) had postoperative transthoracic echocardiography (TTE) within 6 weeks of surgery. The subgroups of patients undergoing intraoperative TEE and postoperative TTE had preoperative characteristics similar to the overall group. The 30-day operative mortality was 2.9% (). Intraoperative TEE downgraded the severity of MR to mild or less (0 to 2+) in 89% (). On postoperative TTE, 40% () continued to have at least moderate MR (3 to 4+), 51% () improved somewhat to mild (2+) MR, and only 9% () had resolution of their MR (0 to 1+). The mean preoperative, intraoperative, and postoperative MR grades were 3.0+/-0.0, 1.4+/-1.0, and 2.3+/-0.8, respectively (P<0.001)., Conclusions: CABG alone for moderate ischemic MR leaves many patients with significant residual MR and may not be the optimal therapy for most patients. Intraoperative TEE may significantly underestimate the severity of ischemic MR. A preoperative diagnosis of moderate MR may warrant concomitant mitral annuloplasty.

We reviewed our experience with minimally invasive direct-access mitral valve surgery in 207 patients through February 1999. Three patients underwent associated procedures, a coronary artery bypass graft (CABG) with right internal mammary artery to right carotid artery (RIMA-RCA), a left ventricular outflow tract (LVOT) debridement for endocarditis, and a primum atrial septal defect (ASD) repair, and were excluded from analysis. Of the 204 remaining patients, 120 (59%) patients were men, aged 58.7 +/- 13.2 years, functional class of 2.3 +/- 0.5. The cause was myxomatous in 162 (79%) patients, rheumatic in 28 (14%) patients, endocarditis in 8 (4%) patients, congenital in 3 (2%) patients, and ischemic in 3 (2%) patients. Mean preoperative EF was 60% +/- 10%, with 184 (90%) patients showing ejection fraction (EF) greater than 50%. The valve was approached through a 5- to 8-cm right parasternal (n = 180, 88%) or right inframammary (n = 24, 12%) incision. One hundred nineteen (58%) patients had open femoral artery-femoral vein cannulation, and 85 (42%) patients had direct cannulation of the aorta and percutaneous cannulation of the femoral vein. One hundred seventy (83%) patients underwent successful valve repair, and 34 (17%) patients required valve replacement. The mean duration of aortic clamping and cardiopulmonary were, respectively, 100 +/- 34 and 146 +/- 44 minutes. There were 2 (1%) surgical deaths. Nonfatal perioperative complications included 3 (1.5%) ascending aortic complications, 3 (1.5%) reoperations for bleeding, 4 (2%) strokes, 2 (1%) transient ischemic attacks (TIAs), 2 (1%) myocardial infarctions, 3 (1.5%) pericardial effusions requiring drainage, 9 (4.5%) vascular complications, and 3 (1.5%) wound complications. Mean length of stay (LOS) was 6.1 +/- 3 days, with 63 (31%) patients being discharged in less than 5 days. One hundred twenty-nine (63%) patients did not require blood transfusions. Follow-up was complete in 165 (81%) patients, with mean follow-up of 13.2 +/- 8 months. Late complications included 1 (0.5%) myocardial infarction, 3 (1.5%) reoperations, all converting repairs to replacements, 3 (1.5%) wound hernias requiring reoperation and repair with mesh, 5 (2.5%) thromboembolic events, and 3 (1.5%) deaths of suicide, pneumonia, and sudden death, respectively. Mean follow-up New York Heart Association (NYHA) functional class was 1.2 +/- 0.5. We conclude that minimally invasive direct-access mitral valve surgery is safe, effective, and applicable for most patients presenting for isolated mitral valve surgery. We now consider it the standard of care for selected patients.

Background: Volume overload secondary to mitral regurgitation (MR) in cardiomyopathy is considered critical in the pathogenesis of subsequent ventricular dysfunction. Open mitral valve repair (OMVP) is hypothesized to improve symptomatology and ventricular function by reducing the volume overload of the left ventricle., Methods and Results: All patients who underwent OMVP with a left ventricular ejection fraction (EF) of < 0.30 (n = 81) from 1984 through 1997 were reviewed (1 patient was lost to follow-up). Fifteen operations (18.5%) were repeat operations after previous coronary artery bypass graft surgery. Preoperative and postoperative EFs and NYHA class were compared. Survival probabilities were calculated, and multivariate analysis was performed. The average age of all patients was 67.1 years (range, 41 to 83 years). Mean follow-up was 1.7 years (range, 2 months to 8.5 years). The most common mitral repair was ring annuloplasty. Sixty-two patients (77%) had concomitant coronary artery bypass graft surgery. The surgery mortality rate was 11% (9 of 81); 6 of these 9 patients were > 70 years old. The overall Kaplan-Meier survival probability rate at 1, 2, 3, 4, and 5 years was 0.73, 0.68, 0.58, 0.50, and 0.38, respectively. EF improved significantly (0.24 to 0.32; P < 0.0001), as did the NYHA class (3.2 to 1.6; P < 0.0001), at follow-up. There was no difference in late survival between patients with an EF of < 0.20 (21 patients) and those with an EF between 0.20 and 0.30 (P = NS). Risk factors for death included heart failure and old age., Conclusions: OMVP for MR in the setting of ischemic cardiomyopathy and low EF appear to improve ventricular function, medium-term patient symptomatology, and survival.

Objectives: Our objective was to determine whether direct-access minimally invasive mitral valve surgery can improve recovery and cost while maintaining the efficacy of conventional surgery., Methods: Minimally invasive mitral valve operations were performed on 106 patients, 58% male, average age 58.1 years, with good ventricular function. Ninety underwent repair of a regurgitant, myxomatous valve, and 16 underwent mitral valvuloplasty for prematurely calcified mitral stenosis. The valve was approached with standard instruments through a 5- to 8-cm right parasternal incision. Eighty-five had open femoral artery-femoral vein cannulation, but this technique has recently been replaced by direct cannulation of the aorta and percutaneous cannulation of the femoral vein for most patients., Results: There were no operative deaths. The mean mitral regurgitation score (0-4) decreased from 3.7 to 0.7 after the operation. Although ischemic and bypass times were increased, postoperative recovery was accelerated. Ventilatory support time, intensive care unit stay, hospital stay, need for rehabilitation, and return to "normal activities" all improved. Hospital charges, pain medications, and blood transfusions were also reduced. New atrial fibrillation contributed significantly to increased length of stay and charges. There were no deep wound infections. Other complications included re-exploration for bleeding (n = 1), transient ischemic attacks (n = 2), stroke (n = 1), femoral artery injury (n = 5), pseudoaneurysm (n = 2), and antegrade dissection of the ascending aorta (n = 1). Two patients died and 1 required reoperation during a mean follow-up of 8.8 months., Conclusions: Direct-access minimally invasive mitral valve surgery can accelerate recovery, decrease charges, and decrease pain, while maintaining overall surgical efficacy. It has become our standard approach for isolated primary mitral valve operations.

Mitral valve reconstruction is now the procedure of choice for many mitral regurgitant lesions. Early enthusiasm and technical advances in plastic reconstruction of the mitral valve were overshadowed by the development of prosthetic and bioprosthetic valves. With long-term follow-up studies came the realization that the complication rates of prosthetic mitral valves and the durability of bioprostheses were less than ideal. The use of annuloplasty rings and standardization of mitral repair techniques have made these procedures more universally reliable and the excellent results reproducible. Due to the pathological diversity of mitral regurgitation, many different techniques are used to correct the various lesions. Many centers are reporting hospital mortality, survival, freedom from thromboembolism, freedom from reoperation, freedom from infective endocarditis, and freedom from valve-related complications results that compare favorably with those following mitral valve replacement. The preservation of the papillary muscles and chordae tendinea during mitral reconstruction, as well as a lack of foreign materials, contribute to the enhanced systolic function with improved survival and lower complication rates following mitral repair compared with replacement. With improved results and technical advances, the indications for mitral repair have expanded to encompass a broader diversity of lesions and earlier operative intervention.

Severe posterior annular calcification poses a particular challenge to mitral valve repair. In a series of 252 mitral valve repairs for myxomatous degeneration performed between 1980 and 1993, 14 patients had a severely calcified posterior mitral valve annulus. Ages ranged from 61 to 81 years. Twelve patients were preoperative NYHA Class III or IV, and five patients required concurrent coronary artery bypass procedures. Operative techniques included complete resection of the calcified posterior annulus, resections of portions of the posterior leaflet with leaflet advancement, and placement of an annuloplasty ring. There were no operative deaths and all patients had a postoperative echocardiographic confirmation of relief from mitral regurgitation. During a mean follow-up time of 36 months (6 months to 8 years), there has been one late valve reoperation and only one late death, from thromboembolism in a patient with atrial fibrillation. These data indicate that even in the presence of severe calcification of the posterior mitral annulus, mitral valve repair for myxomatous degeneration can be performed with a low-operative risk and satisfactory long-term results.

Operative correction of ischemic mitral regurgitation (IMR) is associated with high risk approach. The objective of this retrospective study was to examine the interaction between the various underlying pathophysiologic mechanisms, the operative procedure, and their influence on short- and long-term outcomes. Over a 10-year period starting January 1984, mitral valve repair or replacement was performed on 150 patients with IMR. The age range was 42-86, mean 67, years; 71 (47%) were females; 139 (93%) were in NYHA functional class III or IV; 23 (15%) were reoperations; and 30 (20%) were in atrial fibrillation. Functional IMR due to annular dilatation or restrictive leaflet motion was present in 106 (71%), and structural IMR due to ruptured chordae or papillary muscle in 44 (29%). Mitral valve repair was performed in 94 (63%) with an annuloplasty ring employed in 80 (85%) patients. Mitral valve replacement was performed in 56 (37%), with 40 (71%) receiving a bioprosthesis (32 Hancock and 8 Carpentier-Edwards valves) and 16 (29%) a St. Jude valve. Coronary artery bypass graft surgery was performed in 139 (93%) patients. The overall operative mortality (OM) was 14/150 (9.3%). The OM for repair was 9.5% compared to 8.9% for replacement (P = NS). There was higher OM in the elderly, particularly in the repair group (P = 0.053), and a trend towards reduced OM in the recent years of the study (P = NS). No predictors of OM were identified by multivariate logistic regression analysis. Long-term follow-up was 98% complete and ranged from 2-120, mean 31.2, months for a total of 935 patient-years. The overall 5-year survival rate was 71 +/- 6%, with 91 +/- 5% for the replacement group compared to 56% +/- 10% for the repair group (P = 0.01). The functional subset of IMR who had a repair had the worse long-term survival (43 +/- 13%) compared to the structural/repair (76 +/- 13%) and structural/replacement groups (89 +/- 8%), and 92 +/- 7% for the functional/replacement group ((P = 0.0049). Multivariate logistic regression analysis identified the functional/repair group (hazards ratio 4.4; +/- 95%, confidence interval 1.6, 11, (P = 0.0031); and earlier years of surgery (hazards ratio 4.7; +/- 95% confidence interval 1.021; (P = 0.046) to be predictors of worse long-term survival. These results suggest that, in IMR, the underlying responsible pathophysiologic mechanisms appear to be the major determinants of survival, rather than the choice of the operative procedure.

To compare the hemodynamic results of different anuloplasty techniques of primary valve repair for mitral regurgitation, 122 patients were prospectively studied with Doppler echocardiograms 5 to 10 days after operation. Seventy-seven patients had mitral valve prolapse, 27 had coronary artery disease, 13 patients had rheumatic mitral valve lesions and 5 patients had infective endocarditis. Forty-eight patients received the flexible Duran ring, 46 received the more rigid Carpentier ring and 28 patients received no ring. Doppler echocardiography demonstrated a significant decrease in mitral valve area estimated by the pressure half-time method in patients who received either a Carpentier (2.6 +/- 0.8 cm2) or Duran ring (2.8 +/- 0.8 cm2) when compared with patients who received no ring (3.2 +/- 0.7 cm2) (p = 0.01). No significant differences were observed for peak transmitral diastolic velocity, peak transmitral diastolic gradient, or the grade of mitral regurgitation by color flow Doppler mapping between patients with and without rings. The etiology of mitral disease and concomitant surgical procedures accompanying mitral valve repair did not significantly influence mitral valve area, peak velocity or peak gradient. These data suggest that Carpentier and Duran rings decrease the hemodynamic mitral valve area; however, the decrease in valve area is small and not associated with a clinically important increase in transvalvular gradient.

The consecutive 2 year experience with patients undergoing first-time surgery for mitral regurgitation with and without coronary artery disease was reviewed. From January 1988 to January 1990, 127 patients with pure mitral regurgitation undergoing first-time operation were surgically treated. No other valve lesion, no reoperation and no congenital defects were included. The mean patient age was 62 years with 26% of the patients greater than 70 years. Twenty-six percent of the entire group was in functional class IV. Seventy-five patients received mitral valve repair and 52 underwent mitral valve replacement with a St. Jude or Hancock valve. In patients undergoing mitral valve repair, there was a higher incidence of those greater than 70 years old and of coronary artery disease and in patients undergoing mitral valve replacement there was a higher incidence of functional class IV. The operative mortality rate was 2.3% (3 of 127 patients). No patient failed to be discontinued from cardiopulmonary bypass and all three deaths occurred after mitral valve replacement, with one from complications of chronic renal failure and dialysis. There was no significant difference in patients who either did or did not have a concomitant coronary artery bypass graft and there was no difference related to age or functional class. Postoperative complications occurred in five patients in the valve repair group, including recurrent mitral regurgitation in two necessitating reoperation, and in three patients in the valve replacement group. With newer operative and postoperative management techniques, especially preservation of the papillary muscle annular continuity, the risk of mitral valve surgery, particularly of valve repair, is considerably lower than in previous years.

A second case of malfunction of a Harken disk valve due to undue disk wear is reported. Two and one-half years after aortic and mitral valvular replacement, the patient had paraprosthetic aortic insufficiency and physical findings suggesting intermittent dysfunction of his prosthetic mitral valve. Catheterization showed intermittent hemodynamic abnormalities; fluoroscopic and cineangiographic findings indicated intermittent mitral regurgitation secondary to undue mitral disk wear. At operation, the excised valve showed normal struts and sewing ring but severe disk wear. There was loss of disk substance and rim notching.

From January 1, 1972, to January 1, 1981, 1282 consecutive valve replacements were performed at the Peter Bent Brigham Hospital. Fifty-eight of these (4.5%) were rereplacements: 14 for prosthetic valve subacute bacterial endocarditis (SBE), 29 for primary valve dysfunction (PVD) and 15 for perivalvular leak (PVL). Aortic rereplacement was done in 27 patients (eight for SBE, 10 for PVD and nine for PVL) and mitral rereplacement in 31 patients (six for SBE, 19 for PVD and six for PVL). Twenty-six patients were in New York Heart Association functional class III and 32 were in class IV. Ten class IV patients underwent emergency valve replacement (three for SBE, two for PVD and five for PVL). The overall in-hospital mortality rate for valve rereplacement was 14% (eight of 58 patients). For mitral valve rereplacement it was 13% (four of 31), compared with 6.4% (19 of 295) for initial mitral valve replacement. For aortic valve rereplacement, the mortality rate was 15% (four of 27), compared with 5.2% (23 of 440) for initial aortic valve replacement. The cause of death was low cardiac output in six patients, hemorrhage in one patient and sepsis in one patient. All of the patients who died were in functional class IV (p = 0.018). The in-hospital risk for rereplacement of a dysfunctional aortic or mitral valve is no different from that for primary valve replacement unless the patient deteriorates to class IV and requires an emergent operation.

Mitral valve repair has been increasingly used at our hospital for mitral regurgitation with and without coronary disease. From January, 1984, to June, 1987, of 338 patients undergoing all forms of mitral valve surgery, 140 had first-time surgery for pure mitral regurgitation: 75 had valve repair, and 65 had valve replacement. Thirty-three of 75 (44%) had concomitant coronary bypass in the repair group, while 21 of 65 (32%) had coronary bypass in the replacement group. The mean functional class (3.4 versus 3.5), age (60 versus 61 years), and preoperative hemodynamics were similar in both groups. The cause of mitral regurgitation in the repair group was myxomatous change in 32 patients, ischemia in 27, rheumatic valve disease in 12, and endocarditis in 4. A Carpentier ring was used in 46, a Duran ring was used in 11, and none was used in 18. The operative mortality was 3 of 75 patients (4%) in the repair group, all with coronary artery bypass grafting, versus 2 of 65 patients (3%) in the replacement group, 1 of whom had undergone coronary artery bypass grafting. The mean postoperative functional class 15 months postoperatively was 1.12 in the repair group versus 1.15 in the replacement group. There were 7 late deaths in the replacement group and only 3 late deaths in the repair group. Actuarial survival at 30 months was 85 +/- 6% for the replacement group and 94 +/- 4% for the repair group. There were 5 late emboli (1 fatal, 4 nonfatal) after valve replacement and none after valve repair (p = 0.03).(ABSTRACT TRUNCATED AT 250 WORDS)

From 1984 to 1988, 129 mitral valve reconstructions were done for primary pure mitral regurgitation. Sixty-two (48%) were done for myxomatous degeneration and prolapse of the mitral valve. Anterior leaflet resection was performed in seven patients, posterior leaflet resection in 46, anteroposterior resection in four; five patients received only a ring annuloplasty. Eight patients had coronary bypass grafts. Twenty-four patients received a Carpentier-Edwards annuloplasty ring, 24 a Duran ring, and 14 patients had no ring. Follow-up was 1 to 50 months (mean, 13 months). No patient was lost to follow-up. There was one operative death from gastrointestinal bleeding and two late deaths (one from suicide and one from a myocardial infarction), and the probability of survival at 48 months was 84% +/- 15%. There were no thromboembolic episodes or episodes of endocarditis. However, there were five reoperations (9%) with freedom from reoperation at 48 months of 85% +/- 5%. There was one major anticoagulant hemorrhage. Freedom from all morbidity at 48 months was 81% +/- 8%. Postoperative echocardiographic data in the three different groups of patients undergoing repair on the basis of annuloplasty treatment showed that the peak gradient was less and the valve area was slightly greater with no annuloplasty ring.

A consecutive series of 706 mitral valve replacements was performed from January, 1972, to January, 1984. The follow-up ranged from 6 to 150 months with a mean of 50 and a median of 43 months. Seven percent (50) of the patient were lost to follow-up. There were 243 men and 463 women, whose ages ranged from 17 to 86 years (mean 58). A porcine bioprosthetic valve was implanted in 528 patients (514 Hancock and 14 Carpentier-Edwards valves) and a prosthetic disc valve in 178 patients (102 standard disc Björk-Shiley, 34 Beall, and 42 Harken disc valves). Seven patients were in Functional Class II, 325 in Class III, and 374 in Class IV. A concomitant operative procedure was performed in 253 of the 706 patients (36%). Mitral regurgitation was the primary hemodynamic lesion in 363 and mitral stenosis in 343. Operative mortality figures were as follows: 77 of 706 (11%) for the overall group, 34 of 453 (7.5%) for isolated mitral valve replacement, 30 of 169 (17.5%, p = 0.001) for mitral replacement plus coronary bypass, 49 of 528 (9%) for the bioprosthetic valve group, and 28 of 178 (16%) for the prosthetic disc valve group (p = 0.01). After the operation, 262 patients were in Functional Class I, 99 in Class II, and 18 in Class III. The long-term survival rate was significantly lower in patients who had an associated procedure (45% +/- 6%), who had mitral regurgitation rather than mitral stenosis (53% +/- 5% versus 67% +/- 4%) (p = 0.002), who were in Functional Class IV rather than Classes I to III (51% +/- 4% versus 70% +/- 4%) (p = 0.001), and who received a prosthetic disc valve rather than a bioprosthesis (40% +/- 6% versus 67% +/- 4%) (p = 0.001). Thromboembolic rates were significantly higher with prosthetic valves than with bioprosthetic valves (4.6% +/- 0.22% versus 2.4% +/- 0.5% per patient-year of follow-up), and the incidence of anticoagulant-related hemorrhage was significantly higher in the prosthetic valve group (1.65% versus 0.43% per patient-year). Primary valve dysfunction was significantly more common in the bioprostheses (1.23% versus 0.40% per patient-year).(ABSTRACT TRUNCATED AT 400 WORDS)

Doppler echocardiographic studies were performed in 21 consecutive patients (mean age 56 +/- 11 years) to evaluate postoperative results of mitral ring anuloplasty. All patients were symptomatic and all had clinically severe isolated mitral regurgitation (MR). The origin of MR was myxomatous degeneration, coronary artery disease, rheumatic heart disease or congestive cardiomyopathy. In 20 patients ring anuloplasty was performed using the Carpentier ring and 1 patient using the Duran ring. Postoperative Doppler echocardiographic studies were performed to detect and semiquantitate residual MR by flow mapping and to identify left ventricular inflow or outflow obstruction. The severity of MR was assessed by flow mapping in the left atrium and graded from I to IV in increasing severity. Blood flow velocity spectra were recorded from the left ventricular outflow tract during systole and from the left ventricle subjacent to the mitral valve during diastole. Pressure half-time, mitral valve area and mitral valve gradient were derived from digitized mitral diastolic flow velocity spectra. After ring valvuloplasty, 9 patients had no MR and 6 had grade I, 3 grade II, 2 grade III and 1 patient grade IV MR. Peak diastolic mitral valve gradient was 8 +/- 4 mm Hg, mean diastolic gradient was 3 +/- 2 mm Hg and pressure half-time was 83 +/- 17 ms, representing a calculated mean mitral valve area of 2.9 +/- 0.8 cm. Peak velocity in the left ventricular outflow tract was 0.9 +/- 0.2 m/s, indicating no obstruction to outflow. Our study confirms that mitral ring valvuloplasty produces a significant reduction in severity of MR, and this is achieved without obstructing left ventricular inflow or outflow.

The cardiac complications of systemic lupus erythematosus (SLE) include a multitude of valvular, myocardial, and pericardial abnormalities resulting from acute and chronic inflammation involving the endocardium, myocardium, and/or pericardium. A case of acute, severe, aortic, and mitral insufficiency occurring as discrete complications of consecutive flares of SLE in the same patient is described with particular emphasis on the clinical and gross pathologic findings. The cardiac complications of SLE, both from a pathologic and clinical standpoint, are reviewed in the context of the uniqueness of this case.

From May, 1974, through December, 1978, 255 mitral annuloplasties have been performed at our institution. Forty-three Carpentier rings and 212 flexible rings were used. Simultaneously, 307 patients with predominant insufficiency were treated with a Hancock bioprosthesis. A critical analysis of the flexible ring group versus the Hancock group is presented: The average ages were 41.3 versus 43.3 years. Preoperatively, 55% versus 60% were in Functional Class III and 9.6 versus 25.4% were in Class IV. The valve lesion was caused by rheumatic disease in 91.2% versus 93.9%. A multiple valve operation was required by 51% versus 60%. There was a significant difference in the operative mortality rates (1.8% versus 11.4%). This difference was maintained for each preoperative functional class and for the isolated and multiple valve groups. There was no significant difference in the late mortality rates (1.4% versus 3.7%). The total actuarial survival rates were of 96.4% and 81% (maximum follow-up times 4.0 and 4.5 years). The incidence of embolism was 2.4% and 4.1% per patient-year, with both groups being subjected to the same anticoagulation policy. The incidence of dysfunctions was equal (3.9% per patient-year). Postoperative hemodynamic evaluation of 72 patients having annuloplasty and 129 patients having Hancock valve replacement showed basal mean transmitral gradients of 10.98 +/- 3.6 and 9.66 +/- 2.73 mm Hg. The average effective orifice areas were 1.93 +/- 0.74 and 2.25 +/- 0.46 cm2. While the bioprosthesis behaves hemodynamically like a flow-related variable orifice, the reconstructed valve orifice is dependent upon its preoperative anatomy. In conclusion, the comparison of flexible ring annuloplasty and Hancock valve replacement for mitral valve disease shows a lower operative mortality for the former and comparable medium-term postoperative course. Since both techniques have a limited durability, longer follow-up periods will soon resolve this controversial issue.

Mitral regurgitation is a valvular heart lesion that is difficult to diagnose accurately; thus, it is difficult to determine the appropriate timing for surgical correction. With increasing use of reparative techniques, including local resection of valve pathology and placement of an annuloplasty ring, and the realization that chronic atrial fibrillation leads to decreased long-term survival, the timing of surgery has changed. In addition, serial noninvasive studies have indicated that despite the absence of symptoms, patients may progress to a myopathic condition if the regurgitation progresses over a long period and surgery is not performed when signs of left ventricular dysfunction are evident. Preservation of the papillary muscle is also extremely important for late postoperative function in patients with mitral regurgitation, and reparative surgery that preserves both anterior and posterior papillary muscle complexes and continuity with the anulus appears to satisfy this assumption. Worldwide experience is reviewed and I present conclusions related to the appropriate indications for mitral valve repair or replacement in patients with mitral regurgitation.