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J Thorac Cardiovasc Surg 2006;132:578-584
© 2006 The American Association for Thoracic Surgery

Surgery for Acquired Cardiovascular Disease

Papillary muscle repositioning for repair of anterior leaflet prolapse caused by chordal elongation

Department of Cardiothoracic Surgery, Royal Brompton and Harefield NHS Trust London, Harefield Hospital, Harefield, Middlesex, United Kingdom.

Received for publication January 31, 2006; revisions received May 30, 2006; accepted for publication June 7, 2006.

^_* Address for reprints: Gilles Dreyfus, MD, PhD, FRCS, Department of Cardiothoracic Surgery, Royal Brompton and Harefield NHS Trust London, Harefield Hospital, Hill End Rd, Harefield, Middlesex UB9 6JH, United Kingdom. (Email: g.dreyfus{at}rbh.nthames.nhs.uk).

OBJECTIVE: Anterior leaflet prolapse is still a challenge. Various techniques have been described, but very little is known of the long-term outcome. We describe the long-term results of papillary muscle repositioning, with up to 15 years' follow-up.

METHODS: From 1989 through 2005, 120 patients with anterior leaflet prolapse (97 bileaflet and 23 isolated anterior leaflet) were treated with papillary muscle repositioning when chordae were elongated. All patients had severe mitral regurgitation. The mean left ventricular end-systolic diameter on echocardiography was 39.4 ± 5.2 mm. The predominant cause was degenerative: dystrophic disease in 62 and Barlow's disease in 43. Papillary muscle repositioning was carried out on the posterior papillary muscle in 92.5% and on the anterior papillary muscle in 31.7%. A ring annuloplasty was performed in 117 cases. Fifty-seven (47.5%) patients had a tricuspid annuloplasty.

RESULTS: There were no in-hospital deaths or patients lost to follow-up. Mean follow-up was 6.3 ± 0.4 years (maximum, 15.6 years). Cumulative actuarial survival at 5, 10, and 15 years was 97.2%, 94.1%, and 81.4%, respectively. Two (1.7%) patients required reoperation at 1 and 5 years after repair. No significant risk factor was identified for late mortality or reoperation. At the latest assessment, 88 (73.3%) patients were asymptomatic. Echocardiography showed no or trivial mitral regurgitation in 89 (74.2%) patients, mild mitral regurgitation in 8 patients, and moderate mitral regurgitation in 9 patients.

CONCLUSIONS: Anterior leaflet prolapse caused by elongated chordae can always be addressed with papillary muscle repositioning. Results indicate that it is a safe and durable technique, providing good long-term results in the management of degenerative pathology of the anterior leaflet.

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