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\begin{document}

\title{Anterior Leaflet Prolapse. To repair or Not to repair?}



\author[1]{Guglielmo Actis Dato}%
\author[2]{Giulia Actis Dato}%
\affil[1]{Azienda Ospedaliera Ordine Mauriziano di Torino}%
\affil[2]{Maastricht UMC+}%


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  \date{May 21, 2024}


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\begin{abstract}
A larger use of mitral valve repair is recommended in case of mitral
regurgitation. Anterior leaflet repair is generally more difficult than
posterior. Presence of atrial fibrillation or dysfunction of left
ventricle appears to be independent preoperative factors of failure in
case of involvement of the anterior leaflet. In experienced hands
anterior leaflet repair can be effective and safe and should
theoretically not limit a conservative technique instead of a
replacement. This would therefore lead to being more aggressive in the
treatment of this pathological condition in the earlier stages of the
disease.%
\end{abstract}%



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Author name: Actis Dato Guglielmo M., MD, Actis Dato Giulia, MD

Affiliation: Cardiac Surgery, Mauriziano Hospital Umberto I, Turin,
Italy

Short Title: Anterior Leaflet Repair

Corresponding author details: Cardiochirurgia, Ospedale Mauriziano,
largo Turati, 10125 Torino, Italia

Stajanovic and coll. compared data of 74 patients operated on for mitral
valve repair in anterior leaflet prolapse with a randomly assigned 74
cases of posterior repair of mitral valve in a period of 11 years in the
same Center (1).

Repair of the mitral valve historically represents a cornerstone of
cardiac surgery in its beginnings. Hundreds of thousands of patients
were operated on beating heart for rheumatic disease in case of valve
stenosis trough commissurothomy (2).~ In the following years advent of
extracorporeal circulation, has also become possible repair in cases of
mitral insufficiency (3). This~ stimulated surgeons to perform this type
of surgery on an increasing number of patients with good results~ (4).
Valve repair in the event of failure related to a posterior leaflet
disease has been standardized during the 1990s. This has allowed~ to
obtain excellent results especially when associated with annuloplasty by
using a ring (5). Vice versa, anterior leaflet disease historically
suffered from a lower incidence of success in the follow-up and this
discouraged the use of repair techniques in the past. Undoubtedly,
surgical techniques necessary to obtain a good immediate and remote
result after an anterior leaflet repair are more complex and not always
easily reproducible as they are less standardized. Minimum intervention
volume to be performed by a surgeon who deals with this type of
pathology is considered to be at least 25 repairs per year. David and
collaborators demonstrated that isolated anterior mitral prolapse repair
in a median follow-up of 10 years is a significant predictor of
recurrent regurgitation and re-operation even when performed by a
single, more experienced surgeon (6). Particular care should therefore
be taken when interpreting insignificant differences in the risk of
re-operation after mitral repair in the anterior and posterior leaflet.
With this paper Stojanovic and collaborators encourage a wider use of
anterior leaflet repair if performed in specialized centers of
excellence and with significant surgical volumes. ~Nevertheless presence
of atrial fibrillation or dysfunction of left ventricle appears to be
indepedent preoperative factors of failure in case of involvement of the
anterior leaflet.

This would therefore lead to being more aggressive in the treatment of
this pathological condition in the earlier stages of the disease.
Authors should be congratulated for having highlighted and encouraged to
always evaluate the potential benefit of mitral repair even in the
presence of a defect involving the anterior leaflet.

In experienced hands anterior leaflet repair can be effective and safe
and should theoretically not limit a conservative technique instead of a
replacement.

1~Stojanovic I~ et al~~ Clinical and echocardiographic predictors of the
anterior mitral leaflet repair failure.~ J Card Surg~ 2022

2~Bajaj SS, Fann JI.~ History of Surgery for~Mitral~Stenosis: John Mayow
to Charles~Bailey. Ann Thorac Surg. 2022 Jun;113(6):2097-2101.

3~Kay JH, Tsuji HK, Redington JV, Yokoyama T. Surgical Treatment of
Mitral Insufficiency

Calif Med. 1967 Oct; 107(4): 311--314.

4 Actis Dato GM, Zingarelli E, Flocco R, Tomasello A, Del Ponte S, Punta
G, Forsennati P, Casabona R.~~ A 43-year follow-up after mitral valve
repair. J Cardiovasc Surg (Torino). 2009 Jun;50(3):415-6.

5~Deloche A, Jebara VA, Relland JY, Chauvaud S, Fabiani JN, Perier P,
Dreyfus G, Mihaileanu S, Carpentier A.~
Valve~repair~with~Carpentier~techniques. The second decade.~ J Thorac
Cardiovasc Surg. 1990 Jun;99(6):990-1001; discussion 1001-2.

6~David TE, Armstrong S, McCrindle BW, Manlhiot C.~ Late~outcomes
of~mitral~valve~repair~for~mitral~regurgitation due to degenerative
disease.~ Circulation. 2013 Apr 9;127(14):1485-92.

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