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J Thorac Cardiovasc Surg 2008;136:1200-1206
© 2008 The American Association for Thoracic Surgery

Surgery for Acquired Cardiovascular Disease

How does the use of polytetrafluoroethylene neochordae for posterior mitral valve prolapse (loop technique) compare with leaflet resection? A prospective randomized trial

^a Heart Center Leipzig, Leipzig, Germany
^b Cardiovascular Center Bad Neustadt, Bad Neustadt, Germany

Received for publication May 10, 2008; revisions received July 9, 2008; accepted for publication July 14, 2008.

^_* Address for reprints: Joerg Seeburger, MD, Heart Center Leipzig, Leipzig University, Struempelstrasse 39, 04289 Leipzig, Germany. (Email: j.seeburger{at}web.de).

Objective: Mitral valve surgery for posterior mitral leaflet prolapse consists mostly of leaflet resection, but implantation of premeasured polytetrafluoroethylene neochordae (ie, loops) is another option. The aim of this prospectively randomized trial was to determine how preservation of leaflet structure in combination with premeasured neochordae compares with the widely adopted technique of leaflet resection.

Methods: A total of 129 patients with severe mitral regurgitation, with a mean mitral regurgitation grade of 3.6 ± 0.6, underwent minimal invasive mitral valve surgery through a right lateral mini-thoracotomy. The mean age was 59.5 ± 12 years, 90 patients were male, the mean preoperative ejection fraction was 65% ± 8%, and the mean New York Heart Association functional class was 2.1 ± 0.7. Posterior mitral leaflet prolapse was diagnosed in all patients. Randomization was performed preoperatively, and crossover was allowed if the surgeon deemed it medically necessary. Crossover from resection to loops occurred in 9 patients, and crossover from loops to resection occurred in 3 patients.

Results: Mitral valve repair was accomplished in all patients (n = 129, 100%), and all patients received an annuloplasty ring. The mean number of loops implanted on the posterior mitral leaflet was 3.2 ± 0.9, with a mean length of 13.3 ± 2.2 mm. The mean duration of cardiopulmonary bypass was 135 ± 37 minutes and the mean aortic crossclamp time was 82 ± 26 minutes in all patients, with no significant difference between groups. Intraoperative transesophageal echocardiography showed a significantly longer line of mitral valve leaflet coaptation after implantation of loops (7.6 ± 3.6 mm) than after resection (5.9 ± 2.6 mm; P = .03). Thirty-day mortality was 1.6% for the entire group (2/129), with both deaths occurring in the loop group. Cause of death was massive pulmonary embolism in 1 patient and acute right heart failure in 1 patient. Early and mid-term echocardiographic follow-up revealed excellent valve function in the majority of patients, with no significant difference in mitral orifice area (3.6 ± 1.0 cm² vs 3.7 ± 1.1 cm², P = .4).

Conclusion: Both repair techniques for posterior mitral leaflet prolapse are associated with excellent results and appear comparable in the early postoperative course. The loop technique, however, results in a significantly longer line of leaflet coaptation and may therefore be more durable. Longer follow-up is required.