Conclusion
The aims of each and every MVr, whatever the technique used, must be to
restore a coaptation height between A2 and P2 of 8 to 10 mm, to restore
coaptation depth, to respect leaflet mobility and to achieve a
harmonious 2/3 – 1/3 (even 3/4 – 1/4) closure line.
The concept of « respect without resection » sounds very appealing as it
is easy and fast to perform. Therefore, it has gained further
popularity, especially with minimally invasive MV surgery approach .
Our personal opinion is that the « respect » technique’s major drawback
is related to the tension applied to the chordae as keeping all the
pathological tissue necessarily increases the tension on them. In turn,
this leads to early failures due to recurrent prolapse with or without
chordal rupture or tear of the leaflet.
The coaptation height (which is measured in end systole in between A2
and P2) is never equal to the height of P2. This technique brings an
asymmetrical coaptation with the tip of A2, and, therefore, a false
sense of security given that one could believe that « the reserve of
coaptation » of the new MV is very high.
Another issue with the concept of non-resection is the mandatory pulling
of P2 downwards in the left ventricle, so that the indentations become
wide open and require closure, as P2 is not at the same level as P1 and
P3 anymore. As opposed to this technique the resection technique never
open the indentations and their closure is not necessary .
Finally, the ultimate goal of all mitral repair strategies should be to
decrease excess tension at each and every level of the mitral apparatus.
We therefore believe that oversimplification applicable to all mitral
repairs such as artificial chordae and ring annuloplasty is quite
appealing but surely not realistic. Moreover, patients need to do well,
early and later, in order to keep mitral repair as the gold standard
[4]. Little is known about the long-term results of those advocating
such simplification. Major recognized surgical teams in the world,
showing results with a follow up of 10 years or more and with
longitudinal echocardiographic data, use a variety of resection
techniques as a key point in the treatment of most degenerative MV
diseases (Cleveland Clinic, Mayo Clinic, Toronto General Hospital, Mount
Sinai,…[8,9,10,11,12,13,14] ), as we also do.