"Respect when you can, resect when you should": A realistic approach to posterior leaflet mitral valve repair.

OBJECTIVE: Avoiding resection to treat posterior leaflet prolapse has become popular to repair degenerative mitral regurgitation. We never subscribed to such simplification but advocated an alternative approach based on the "respect when you can, resect when you should" concept. The present study reviewed posterior leaflet prolapse in degenerative disease with the aim to expose the 10-year experience with this surgical policy, in particular long-term outcomes such as survival, recurrent/severe mitral regurgitation, and reoperation. METHODS: From January 2005 to December 2015, 701 consecutive patients with severe mitral regurgitation underwent mitral valve repair in 2 distinct institutions. Mitral regurgitation was degenerative in 441 patients, of whom the 376 with posterior leaflet prolapse constituted the study population. Patients were followed up by echocardiograms until December 2017. Longitudinal data stratified by institution were analyzed by mixed-effects models. Outcome measures were analyzed by Kaplan-Meier test. RESULTS: Patients with posterior leaflet prolapse (24.7% isolated P2 and 75.3% P2 associated with other segments) were aged 65.8 +/- 13 years, and 70.5% were male. Median follow-up was 61.1 months. There were 3 hospital deaths (0.8%). Reoperation was necessary in 7 patients (1.9%). After 1, 5, and 10 years, overall survival was 97.8%, 93.6%, and 86.7%, respectively; the overall survival of the proportion of patients with recurrent/residual >2+ mitral regurgitation was estimated at 0.7%, 1.9%, and 5.9% and that of patients with New York Heart Association III/IV at 0.8%, 1.9%, and 5.3%. CONCLUSIONS: The "resect with respect" approach yields low operative mortality, no systolic anterior motion, good surface of coaptation, and low incidence of residual/recurrent mitral regurgitation and of reoperation, thus supporting resection when required concept.