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\begin{document}

\title{MORPHO-FUNCTIONAL ANALYSIS OF THE REGURGITANT MITRAL VALVE AS A GUIDE TO
REPAIR: ANOTHER POINT OF VIEW}



\author[1]{Antonio Calafiore}%
\author[2]{Sotirios Prapas}%
\author[1]{Antonio Totaro}%
\author[3]{Stefano Guarracini}%
\author[2]{Kostas katsavrias}%
\author[4]{Michele Di Mauro}%
\affil[1]{Department of Cardiovascular Diseases Gemelli Molise Campobasso Italy}%
\affil[2]{Errikos Ntynan Hospital Center}%
\affil[3]{Department of Cardiology “Pierangeli” Hospital Pescara Italy}%
\affil[4]{Universiteit Maastricht Cardiovascular Research Institute Maastricht}%


\vspace{-1em}



  
  \date{May 05, 2024}


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\selectlanguage{english}
\begin{abstract}
Based on Carpentier's classification and principles, the techniques for
mitral valve repair continue to evolve. We herein report our experience
with the morpho-functional echocardiographic analysis of single mitral
leaflets, as different anatomic features, even if conflicting, may
coexist not only in the two leaflets, but in the same leaflet as well. A
classification is proposed, based on the length (normal, short, or long)
and mobility (normal, restricted, or excessive) of mitral leaflets. The
surgical techniques adopted for mitral valve repair are the direct
consequence of this analysis.%
\end{abstract}%



\sloppy


\textbf{MORPHO-FUNCTIONAL ANALYSIS OF THE REGURGITANT MITRAL VALVE AS A
GUIDE TO REPAIR: ANOTHER POINT OF VIEW}

Antonio Maria Calafiore (a), MD, Sotirios Prapas (b), MD, Antonio Totaro
(a), MD, Stefano Guarracini (c), MD, Kostas Katsavrias (b), MD, Michele
Di Mauro (d), MD, PhD, MSC, FESC

\begin{enumerate}
\tightlist
\item
  Department of Cardiovascular Diseases, Gemelli Molise, Campobasso,
  Italy
\item
  Division of Cardiac Surgery A, Henry Dunant Hospital, Athens, Greece
\item
  Department of Cardiology, ``Pierangeli'' Hospital, Pescara, Italy
\item
  Cardio-Thoracic Surgery Unit, Heart and Vascular Centre,
  Cardiovascular Research Institute Maastricht (CARIM), Maastricht
  University Medical Centre (MUMC), Maastricht, The Netherlands
\end{enumerate}

\emph{Corresponding author:}

Antonio Maria Calafiore, MD

Department of Cardiovascular Diseases, Gemelli Molise, 86100 Campobasso,
Italy

Tel: +39 0874 312403

e-mail: am.calafiore@gmail.com

\textbf{Keywords} : mitral valve repair, morpho-functional analysis,
mitral valve prolapse, secondary mitral regurgitation



\textbf{ABSTRACT}

Based on Carpentier's classification and principles, the techniques for
mitral valve repair continue to evolve. We herein report our experience
with the morpho-functional echocardiographic analysis of single mitral
leaflets, as different anatomic features, even if conflicting, may
coexist not only in the two leaflets, but in the same leaflet as well. A
classification is proposed, based on the length (normal, short, or long)
and mobility (normal, restricted, or excessive) of mitral leaflets. The
surgical techniques adopted for mitral valve repair are the direct
consequence of this analysis.

Surgical experience with mitral valve repair (MVr) for mitral
regurgitation (MR) started since the '50s, demonstrating the will of
surgeons to go beyond the technical limitations of closed heart surgery
while moving to open heart surgery. The most important chapter in the
huge book on MVr was however written by Carpentier et
al\textsuperscript{1,2}, who defined the terms and introduced the
principles that, with some modifications, are still followed by many
surgeons. His vision, together with the concept of
annuloplasty\textsuperscript{3} and the advent of artificial
chords\textsuperscript{4}, are the pillars on which MVr surgery stands.

Globally, many techniques have been proposed to correct MR, but
countless variants have been described to modify, simplify, or making
each of these techniques more complicated. As a consequence, any surgeon
dedicated to MVr developed his own strategy to stay afloat in these deep
and stormy waters, trying to pick up the concepts he thought to be the
most appropriate for him.

Our long journey started in 1990 and since then, step by step, our
understanding of MVr has advanced, with the purpose of making MR
correction as easy as possible. In this report, we describe our approach
to MVr and the questions to be answered to plan a correct surgery.

\textbf{CORRECTION OF} \textbf{MITRAL REGURGITATION}

Regardless of the etiology, surgical correction of MR is aimed at
changing a bileaflet valve where both cusps are moving into a bileaflet
valve where only the anterior leaflet (AL) moves whereas the posterior
leaflet (PL) is fixed and motionless in vertical position and represents
only a door frame for the AL. Both leaflets meet at the edge of the
mitral area, avoiding systolic anterior motion (SAM) to occur. This
means that the final echocardiographic result is always the same and
does not change according to etiology (Figure 1).

To reach this goal, we need to follow two steps: first, to examine
echocardiographic anatomy and function of both leaflets, and then to
group findings in such a way to address surgical correction.

\textbf{ECHOCARDIOGRAPHIC ANALYSIS}

The morpho-functional echocardiographic analysis of the mitral valve
leaflet anatomy is the most important step to identify the underlying
lesions and mechanisms of MR in order to define the appropriate surgical
strategy. We need then:

* To assess leaflet length . The AL should be long enough to close the
mitral area, coapting properly with the PL. The PL should be long enough
to offer a good coaptation surface to the AL when fixed in vertical
position. However, it should not be too long so in order to avoid any
movement that may bring coaptation with the AL inside the mitral area.
In general, the excess of AL length and the reduced PL length are not
important, as the former will add length to the coaptation, whereas the
latter is irrelevant, unless it is, more or less, below 10 mm. Then,
according to the length, the leaflets can be classified as normal,
short, and long.

* To assess leaflet mobility . If the AL movement is restricted, this
would not allow the AL to reach the PL or may reduce the length of the
coaptation with the PL. Conversely, if the AL movement is excessive, the
AL will continue to coapt properly with the PL. If the PL movement is
excessively restricted, the PL position could be not vertical, but
posteriorly directed, avoiding the AL to coapt. In contrast, if the PL
movement is excessive, the PL will not reach the vertical position, but
will meet the AL inside the mitral area with the possibility of causing
SAM. Then, according to mobility, the leaflets can be classified as
normal, restricted, and excessive.

* To position a ring or a band to fix the PL in vertical position.

The information we obtain from mitral leaflet analysis can lead to
a\textbf{surgical classification} , with first the leaflet (AL or PL),
then the length and after the mobility for each of them. For instance,
if the AL length is short and tethered, and the PL is long and
prolapsing, this feature can be defined as AL(short with restricted
mobility) and PL(long with excessive mobility) (Figure 2). The same
leaflet may also show two different abnormalities. In Figure 3, the PL
has normal length and mobility, and the AL is long, but tethered and
prolapsing. This feature can be classified as AL(long with both
restricted and excessive mobility) and PL(normal with normal mobility),
focusing where to address the correction.

\textbf{SURGICAL STRATEGIES}

Let us now examine the mitral valve leaflets to answer the previous
questions and to decide the proper strategy to correct any anomaly.

\textbf{Leaflet length (Table 1)}

Anterior mitral leaflet . The normal length of the AL is
23.4\selectlanguage{ngerman}±2.9\textsuperscript{5}, but, in our practice, we always considered
26 mm the minimum length necessary to obtain a competent valve. This is
supported by a study of Gupta et al\textsuperscript{6}, who found that
26 mm was the cut-off value for a successful MVr in patients with
rheumatic disease. With this cut-off in mind, AL length can be normal
(26 to 30 mm), short (\selectlanguage{english}[?]25 mm), or long (\textgreater{}30 mm).

\emph{Normal} . Nothing has to be done.

\emph{Short.} This causes a potentially dangerous situation as it may
avoid the AL to reach the PL or may reduce the coaptation length (CL).
It is independent of the etiology, either primary or secondary. In this
eventuality, patch augmentation (always accompanied by second-order
chord cutting) is the solution (Table 1, A-C). The position of the
primary chords will not change, but the coaptation with the PL will
increase.

\emph{Long.} The excess length does not create problems, as it increases
only the CL, provided the PL remains in vertical position, motionless,
at the border of the mitral area (Figure 4). An excess of AL length may
be corrected only if asymmetric septal hypertrophy coexists with severe
MR and the AL is too long (Figure 5). The procedure is performed through
the same aortotomy.

\emph{\textbf{Posterior mitral leaflet}.} The normal length of the PL is
13.8+-2.9 mm\textsuperscript{5}. As the PL has to maintain a vertical
position, from the surgical point of view a cut-off length of 11 to 15
mm would be appropriate.

\emph{Normal.} (11-15 mm), nothing has to be done.

\emph{Short.} (\selectlanguage{english}[?]10 mm), as typically happens in rheumatic MR, patch
augmentation (with chordal cutting) will restore the vertical position
we are looking for (Table 1, D).

\emph{Long.} An excess of PL length is associated with prolapse, which
can be localized to one (typically P2) or more scallops. As our purpose
is to join all scallops to allow a reciprocal support, the height of the
scallops should be more or less equal. The longitudinal plication of the
long scallop(s)\textsuperscript{7} will make the height similar,
facilitating scallop suturing (Table 1, E-F).

\textbf{Mobility (Table 2).}

Anterior mitral leaflet .

\emph{Normal} . Nothing has to be done.

\emph{Restricted} . The limitation can be at the level of the first or
second-order chords. In the first case, typical of rheumatic valves, the
decision is difficult and will depend on the specific anatomy. A
solution can be patch augmentation to facilitate leaflet coaptation, but
in other cases cutting all the first-order chords and their replacement
with artificial chords is the only solution. However, this is an extreme
solution. If the restriction is at the level of the second-order chords
(the most frequent feature), the AL is augmented with a pericardial
patch and the second-order chords are cut (Table 1, A-C). This typically
occurs in ischemic or non-ischemic functional MR. In both cases, we
prefer to increase the AL length in order to increase the CL. However,
if AL length is normal, we prefer to cut the second-order chords through
a transaortic approach\textsuperscript{8} (Table 2, A). Second-order
chord tethering can be present in degenerative disease as well, as
recently reported by Sakaguchi et al\textsuperscript{9}, causing
moderate or greater MR during follow-up after correction of PL prolapse.
Our group described a case of intermittent tethering of second-order
chords of the AL causing left ventricular outflow tract obstruction and
severe MR. Second-order chords were cut during a second pump run, with
immediate resolution of both MR and obstruction\textsuperscript{10}. Any
second-order chord tethering, even if mild, should be avoided in any
patients, regardless of the etiology of valve regurgitation (Figure 6).

\emph{Excessive} . It is due to elongated or ruptured chords. In both
cases, the correction is achieved by adding artificial chords. In most
cases, two pairs of Gore-Tex 4/0 or 5/0 sutures positioned at the A2
level, close to A1 and A3, are sufficient. There are many techniques to
decide the length of the neo chords. In 2008, we described a technique
that works every time and it is very simple\textsuperscript{11}.
Briefly, the AL is pulled up, at its maximum extension, toward the left
atrial central point. Then the artificial chord is tied 5 mm higher than
the AL border where it is passing through (Table 2, B). There are
several reasons for this choice. First, during diastolic cardiac arrest,
the position of the mitral valve is higher than normal and we have no
reference point to decide the correct length. Second, artificial chords
are not elastic as native chords are. Third, the position in the left
atrium of any prolapsing AL segment always does not exceed 2-3 mm above
the mitral annulus, which makes possible to use the same concept for all
prolapsing segments, all of which being the reference point for itself.
In case of ruptured chords, the 5 mm extra height can be calculated
using the closest non-prolapsing AL segment (Table 2, C) or tying the
Gore-Tex suture at the same level as the artificial chord if the closest
segment is prolapsing (Table 2, D).

Posterior mitral leaflet.

\emph{Normal} . Nothing to be done.

\emph{Restricted} . Generally, the restriction is not such to make
correction necessary. If, for any reason, there is the need to increase
leaflet mobility, the solution is patch augmentation with second-order
chord cutting (Table 1, D).

\emph{Excessive} . Chords can be elongated or ruptured. The concept is
always the same: all scallops are sutured each other for reciprocal
support\textsuperscript{12}. If chords are elongated, suturing is the
only maneuver necessary to correct the prolapse (Table 2, E). In case of
extra length (often at P2 level), the scallop(s) is (are) longitudinally
plicated so as all scallops are at the same level, facilitating their
suture. If chords are ruptured, the scallop closer to the ruptured
segment is brought below the unsupported segment and fixed with a U
suture (from the ventricle to the left atrium)\textsuperscript{12}. Once
the border of the scallop is supported with ruptured chords, it is
possible to keep up to 10 mm of the body of the scallop unsupported by
chords. Finally, all the scallops are sutured together (Table 2, F). If
ruptured chords are in the middle P2, a small triangular resection and
scallop suture will correct the lesion.

\textbf{Moderate overreduction}

Once the specific aspects of each leaflet (length and mobility) have
been evaluated and solved, the next step is to reshape the mitral
annulus to obtain a moderate overreduction, in such a way that the PL
will become vertical and fixed. This can be obtained with a complete
ring of any design or with a band. We specifically prefer a 50 mm band
from trigone to trigone, but this is only a personal choice. A moderate
overreduction aims to enhance the CL and to maintain the coaptation
point between the leaflets at the edge of the mitral annulus in order to
prevent the occurrence of anatomic SAM (Figure 4).

\textbf{CONCLUSION}

The morpho-functional approach (length and mobility) to MVr allows us to
correct the specific pathology of each mitral leaflet. We should keep in
mind that apparently conflicting abnormalities may coexist not only in
the same valve, but in the same leaflet as well, and may affect the
success of MR correction. The use of moderate overreduction synchronizes
surgical correction to obtain a competent valve, avoiding anatomic SAM,
an enemy that we must fight against.

The intrinsic mitral valve plasticity\textsuperscript{13} (a term that
defines the adaptability of a living structure to changes in its
environment) can induce a change in leaflet length and mobility. The
mitral valve is not a structure that remains inert if the environment
around it changes, but is able to modify its shape and its
characteristics in the attempt to react to altered geometry and stress
distribution to prevent or reduce regurgitation. Under this aspect, the
mitral valve is a living organism, capable of responding to external
stimuli to counteract any changes that can impair its function
(regurgitation). This can affect the leaflet itself and the chordae
tendinae, which can elongate or thicken or retract due to multiple
mechanisms, mostly driven by activation of the transforming growth
factor-\selectlanguage{greek}β \selectlanguage{english}pathway. Triggers that stimulate the plasticity of the mitral
leaflets and chordae may be either unrelated to valve geometry (e.g.
aortic regurgitation)\textsuperscript{14}, or related to valve geometry
(e.g. changes in mechanical stress)\textsuperscript{15}, MR
itself\textsuperscript{16} or acute myocardial
infarction\textsuperscript{17-19}.

Mitral plasticity is at the basis of any coexisting abnormalities in the
same valve or in the same leaflet, as the adaptation mechanisms may not
be sufficient to reduce MR, inducing thickening and/or retraction of the
leaflets or of the chords. When the adaptive process starts, even if not
effective, it will continue, leading to MVr failure. While it is not
possible to foresee or prevent the future anatomy of the mitral valve,
second-order chords are a variable out of control and we must be very
careful in our decision making at the time of surgery (Figure 6).

The classification we propose is focused on the different anatomical
characteristics related to MR, helping to correct all the
morpho-functional changes that can coexist independently of the etiology
and that likely contribute to regurgitation.



\textbf{FIGURE LEGENDS}

Figure 1 -- TEE. Preoperative. A: bileaflet prolapse. B: tethering of
both leaflets after acute myocardial infarction. Postoperative. C (same
patient as A), D (same patients as B): the AL covers the mitral area and
the PL is motionless in fixed vertical position.

Classification. A: AL (long with excessive mobility)-PL(long with
excessive mobility), typical of Barlow's disease. B: AL (normal with
restricted mobility)-PL (normal with restricted mobility), typical of
IMR.

TEE, transesophageal echocardiography; AL, anterior mitral leaflet; PL,
posterior mitral leaflet; IMR, ischemic mitral regurgitation.

Figure 2 -- TEE. Preoperative. A: the PL is prolapsing, the AL is short
and tethered. 3D reconstruction (B, C) confirms the findings (the arrow
shows AL tethering). Postoperative. D: correction of PL prolapse and
patch augmentation of the AL with second-order chord cutting. From
Calafiore at al\textsuperscript{20}, with permission.

Classification. AL (short with restricted mobility)-PL (long with
excessive mobility)

TEE, transesophageal echocardiography; PL, posterior leaflet; AL,
anterior leaflet; 3D, three dimensional.

Figure 3 -- TTE. PL length and mobility are normal. AL length is normal,
but the leaflet is both restricted (arrow) and prolapsing.

Classification. AL (normal with both restricted and excessive
mobility)-PL (normal with normal mobility).

TTE, transthoracic echocardiography; PL, posterior leaflet; AL, anterior
leaflet.

Figure 4 -- TTE. The AL is long (A), but its length increases only the
coaptation length (dotted line) (B).

TTE, transthoracic echocardiography; AL, anterior leaflet.

Figure 5 -- TEE. Patient with HOCM, severe MR and long AL (A). After
myectomy, the AL was plicated through the aorta (arrow) (B).

TEE, transesophageal echocardiography; HOCM, hypertrophic obstructive
cardiomyopathy; MR, mitral regurgitation; AL, anterior leaflet.

Figure 6 -- TEE. A: persisting tethering of the second-order chords
(arrow) causing mitral valve repair failure after isolated mitral
annuloplasty for IMR. B: 3D reconstruction of the mitral valve and
mitral leaflets. The AL is attracted toward the apex due to further
retraction of the second-order chords (arrow) not cut at the time of the
first repair procedure (same case as in Figure 3).

TEE. Transesophageal echocardiography. IMR, ischemic mitral
regurgitation. AL, anterior leaflet.

A: from Calafiore et al\textsuperscript{20}, with permission. B: from
Calafiore et al\textsuperscript{21}, with permission.



\textbf{REFERENCES}

\begin{enumerate}
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J Card Surg 2020;35:772-8.

Table 1 -- Length of the leaflets.

\textbf{ANTERIOR LEAFLET POSTERIOR LEAFLET}

Normal if 26 to 30 mm: no action if 11 to 15 mm: no action

Short if [?]25 mm if [?]10 mm

PA and CC PA and CC\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image1/image1}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image2/image2}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image3/image3}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image4/image4}

\end{center}
\end{figure}

A B C D

Long \textgreater{}30 mm: no action if \textgreater{}15 mm

longitudinal plication\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image5/image5}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image6/image6}

\end{center}
\end{figure}

E F

A: the AL is detached 5 mm from the annulus from trigone to trigone. B:
the second-order chords (arrows) are evident and cut with a scissor. C:
a pericardial patch is sewn to augment AL length. D, patch augmentation
of the posterior leaflet with a pericardial patch. E, P2 is long and (F)
it is plicated with 4 longitudinal sutures to match the height of the
other scallops.

PA, patch augmentation; CC, chordal cutting; AL, anterior leaflet.

A-C: from Calafiore et al.\selectlanguage{ngerman}²² with permission.

Table 2 -- Mobility of the leaflets.

\textbf{ANTERIOR LEAFLET POSTERIOR LEAFLET}

Normal no action no action

Restricted \emph{at 1\textsuperscript{st} order chords level} no action

PA and CC (see Table 1, A-C )

\emph{at the 2\textsuperscript{nd} order chords level}

AL\textless{}26 mm: PA and CC (see Table 1, A-C )

AL\selectlanguage{english}[?]26 mm: only CC (aortotomy)\selectlanguage{english}
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A

Excessive elongated or ruptured chords elongated chords ruptured chords

artificial chords scallops suture U technique and scallops suture\selectlanguage{english}
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B C D E F

A, the transaortic approach allows to see clearly the second-order
chords, which can be easily cut. B, the AL is pulled up at the maximum
and the distance between the border and the knot is set at 5 mm over the
AL edge. A nerve hook is used for adjustments. In case of chordal
rupture, the height of the knot is set at the same height of another
artificial chord (if the neighbour native chords are elongated) (C) or 5
mm over the border of the AL (if the native chords are not elongated)
(D). E, in case of elongation of the PL chords, the scallops are sutured
together, to receive reciprocal support. F, P2 chordae are ruptured,
mostly close to P3 (A). P3 is sutured below P2 so its chordae will
support part of P2 (B). A portion of P2 remains without chordae. The
scallops are anyway sutured together (C). x, this suture will define the
position of P3 below P2.

PA, patch augmentation; CC, chordal cutting; AL, anterior leaflet; PL,
posterior leaflet.

F, from Calafiore et al\selectlanguage{ngerman}¹², with permission.\selectlanguage{english}
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