Surgical Repair of Posterior Mitral Valve Prolapse: Implications for Guidelines and Percutaneous Repair

Background: Guidelines recommend early surgery for mitral regurgitation (MR) provided repair can be accomplished safely and consistently. However, many patients with degenerative disease are not referred for surgery or undergo replacement rather than repair. Data documenting early and long-term results of surgical repair of posterior prolapse, the most common lesion, are essential to broaden application of repair techniques and provide direction for percutaneous valve repair. This study provides data on long-term survival and valve function after repair of posterior leaflet prolapse. Methods: Of 3,383 patients undergoing surgery for isolated posterior leaflet prolapse, repair was performed in 97%; 3,074 underwent standard quadrangular resection with annuloplasty. Follow-up for survival averaged 6.5 ± 4.5 years and for reoperation, 4.0 ± 3.9 years. Analysis of 4,913 echocardiograms for recurrent MR was performed in a subgroup of 2,575 patients. Results: There were two hospital deaths (0.07%), and 15-year survival was 76%, superior to the age- and sex-matched US population. At 10 years, freedom from mitral reoperation was 97%, and 77% had no or 1+ MR; 11% had 3+ or 4+ MR. Repair durability was jeopardized by failure to use a prosthetic annuloplasty, left atrial enlargement, and left ventricular remodeling and dysfunction. Conclusions: Mitral valve repair for posterior prolapse is a low-risk, durable surgical procedure. The repair must address both leaflet and annulus. Recurrent MR that is moderately severe or severe is uncommon in the decade after operation. These data support recommendations for early surgery and demonstrate that complete repair addresses multiple components of the valve, providing direction for percutaneous approaches.