How does the use of PTFE neochordae for posterior mitral valve prolapse (Loop technique) compare with leaflet resection? Results of a prospective randomized trial
Volkmar Falk1, Markus Czesla1, Joerg Seeburger1, Thomas Kuntze1, Patrick Perrier2, Fitsum Lakev2, Joerg Ender1, Nicolas Doll1, Franka Nette1, Michael A. Borger1, Friedrich W. Mohr1; 1Heartcenter Leipzig, Leipzig, Germany; 2Cardiovascular Center Bad Neustadt, Bad Neustadt, Germany
Comment on this Abstract
Objective: Mitral valve (MV)surgery for posterior mitral leaflet (PML) prolapse consists mostly of leaflet resection, but implantation of premeasured PTFE neochoardae (i.e. loops) is another option. The aim of this prospectively randomized trial was to compare if preservation of leaflet structure in combination with premeasured neochordae can favourably compare to the widely adopted technique of leaflet resection.
Methods: One-hundred and ten patients with severe MV regurgitation (MR), with a mean MR grade of 3.0 ± 0.6, underwent minimal-invasive MV surgery through a right lateral minithoracotomy. Mean age was 58 ± 12 years, 90 patients were male, mean preoperative EF was 65 ± 8%, and mean NYHA functional class was 2.1 ± 0.7. Ninety-five patients were diagnosed with isolated PML prolapse and 15 had bileaflet prolapse. Randomization was performed preoperatively (with an intention-to-treat analysis) and crossover was allowed if the surgeon deemed it medically necessary. In 9 patients crossover from resection to loops occurred, in 3 patients crossover from loops to resection occurred, and 6 patients received both treatment modalities.
Results: MV repair was accomplished in all patients (n=110, 100%). The mean number of loops implanted on the PML was 3.2 ± 0.9 with a mean length of 13.3 ± 2.2mm. Mitral ring annuloplasty was performed in all patients. Intraoperative transesophageal echocardiography showed a significantly longer line of coaptation following implantation of loops (7.6 ± 3.6mm) than following resection (5.9 ± 2.6mm; p=0.03). Postoperative echocardiography showed no significant difference in mitral orifice area (3.6 ± 1.0 vs 3.7 ± 1.1cm2, p = 0.4). Mean duration of CPB was 135 ± 37min and mean aortic crossclamp time was 82 ± 26min in all patients, with no significant difference between groups. Thirty-day mortality was 1.8% for the entire group (2 out of 110), with both deaths occuring in the loop group. Cause of death was massive pulmonary embolism in one and acute right heart failure in the other patient. Early and mid-term echocardiographic follow-up revealed excellent valve function in the vast majority of patients.
Conclusion: Both repair techniques for PML prolapse are associated with excellent results. The loop technique, however, results in a significantly longer line of coaptation and may therefore be more durable. In addition, we feel the loop technique is more reproducible, particularly in patients with extensive PML or bileaflet prolapse.
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