Objectives
Minimally invasive totally endoscopic mitral valve repair (TE-MVR) using 3D visualization is a well-established approach for treating primary mitral regurgitation (PMR). In cases of Barlow’s disease (BD), a complex subset of PMR involving extensive leaflet and annular pathology, TE-MVR poses additional challenges and remains to be investigated.
Methods
From 2012 to 2022, 131 consecutive patients with severe MR due to BD underwent TE-MVR at our center (BD group). Baseline characteristics, surgical techniques, short- and long-term results were retrospectively analyzed, and compared to 304 patients with isolated posterior mitral leaflet prolapse (PML group).
Results
Patients in BD group were younger (BD vs. PML group: 53.0±13.4 vs. 59.9±10.7 years, p<0.001) and more frequently female (46.6% vs. 31.6%, p=0.002). Prevalence of comorbidities and NYHA functional class were similar between groups. Mitral valve replacement was necessary in one patient in each group (0.8% vs. 0.3%, p=0.512) and rates of conversion to sternotomy were comparable (3.1% vs. 1.6%, p=0.344). Cross-clamp time was longer in the BD group (110.8±38.3 vs. 103.1±32.2 min, p=0.046), whereas cardiopulmonary bypass and procedure times were similar. Mean annuloplasty ring size was larger in the BD group (36.3±2.6 vs. 33.0±2.7 mm, p<0.001). For BD group, multiple techniques were used: neochordae to PML (55.0%), neochordae to AML (31.3%), leaflet resection (31.3%), and Alfieri stitch (14.5%) whereas 83.8% of patients in the PML group received annuloplasty and neochordae to PML only. There were no significant differences regarding intra- and postoperative complications, including re-thoracotomy ((6.9% vs.5.0%, p=0.427), low-output syndrome (3.8% vs. 2.0 %, p=0.296), ECMO use (1.5% vs. 1.0%, p=0.640), and atrial fibrillation (30.0% vs. 38.9%, p=0.076). Of note, the incidence of perioperative systolic anterior motion (SAM) was similar between groups (3.1% vs. 1.0%, p=0.205). Thirty-day mortality rates were similar between groups (0.8% vs. 0.3%, p=0.510). Long-term survival at 10 years was similar between groups (90.3±4.8% vs. 91.9±1.5%, p=0.879), as was freedom from re-operation at 10 years (95.5±2.4% vs. 97.8±0.9%, p=0.433).
Conclusion
TE-MVR in patients with complex BD is safe and effective. In comparison to isolated PML prolapse repair, similarly favorable short- and long-term results were achieved, utilizing various MV repair techniques.
