Simple and Safe: Inverse Plication of the Posterior Mitral Leaflet in Everyday Mitral Valve Reconstruction with and without Concomitant Procedures

Objective: Cardiosurgical mitral valve repair (MVR) cannot be easily replaced by other interventional procedures due to the complexity of mitral valve regurgitation as well as physiologic and anatomic repair techniques. A wide variety of techniques have been adopted for proper reconstruction of posterior leaflet prolapse. We investigated the long-term results of quadrangular resections and compared them with a simplified reconstruction maneuver, the inverse plication. Methods: We retrospectively collected data from 1977 patients after mitral valve repair between 2004 and 2022. After considering inclusion and exclusion criteria, we analyzed data from 180 patients after MVR with and without concomitant procedures such as CABG and/or aortic valve replacement (AVR). All MVRs were performed with a semi-rigid annuloplasty ring. A total of 180 patients received quadrangular resection (QuadRes, N = 120)) or inverse plication (InvPlic, N = 60) of the posterior leaflet, among other measures. Demographic data, risk factors, procedure times, hospitalization time, early and long-term mortality as well as Kaplan-Meier survival were analyzed. Results: Age (65.3 vs. 63.1 years) and sex (28.8% female vs. 337.5% female) did not differ significantly, and the EuroSCORE was significantly higher in the InvPlic group (6.46 +/- 2.75) than in the QuadRes group (5.68 +/- 3.1). Procedural times did not differ for cardiopulmonary bypass, and were as follows: InvPlic 136 +/- 44 min; QuadRes 140 +/- 48 min; X-Clamp: InvPlic 91 +/- 31 min; QuadRes 90 +/- 32 min. Hospitalization time was slightly but insignificantly lower in the InvPlic group (15.5 days) than in the QuadRes group (16.1 days). Early mortality (5.08% vs. 8.33%) and re-do procedures (1.69% InvPlic; 6.67% QuadRes) did not differ significantly. However, long-term mortality was significantly lower in the InvPlic group (15.25% vs. 32.32%, p = 0.029). Conclusions: Among the surgical measures for the posterior leaflet, inverse plication appears to be non-inferior to quadrangular resection in unselected all-comer patients. Long-term results and absence of re-do procedures indicate very good stability. Thus, inverse plication not only allows correction of PML, but is also completely safe in the long term and can replace quadrangular resection, especially in patients where a reduction in technical challenges and procedure duration is desired.

Automated summary

This study compared the long-term outcomes of quadrangular resection and inverse plication for posterior leaflet prolapse. The results showed no significant differences between the two surgical methods in terms of patient age, sex, procedural times, and hospitalization time. However, the inverse plication group had significantly lower long-term mortality compared to the quadrangular resection group. Therefore, inverse plication can be a safe and effective alternative to quadrangular resection.