Surgical technique
All surgeries were performed under general anesthesia, oro-tracheal intubation with simple tube or double-lumen tube for the selective exclusion of the right lung. The surgical incision was for all through a cut in the third intercostal space, right anterior mini-thoracotomy (Figure 1). A soft tissue retractor and a rib retractor were used in all patients. A surgical mini-exposure of the femoral artery and vein was performed in all patients, with cannulation of the same and retrograde perfusion through the femoral vessels and combined venous drainage (femoral vein + jugular vein with percutaneous cannulation). Venous drainage was also supported by the use of vacuum. The puncture, the advancement of the Seldinger guide and the cannulae were always performed under trans-esophageal echo guidance. All patients underwent trans-esophageal control for cannulation, control of the mitral reconstruction, control of the cardiac contractile function and the cardiac chamber filling, especially during the infusion of cardioplegic solution and weaning from extracorporeal circulation. In all patients, CO2 was insufflated during the entire surgical phase with open heart cavities. The aortic clamping was external with Cygnet clamp and cardioplegic infusion via antegrade at regular intervals as normothermic blood cardioplegia.
The mitral repair technique has already been described for complex valve reconstructions (7). In summary, in case of posterior flap prolapse (with or without flail), the head of P2 is relocated to the base of P1, with a resection and sliding at the base of P2 (7). At the end of the procedure, a ring for the stabilization of the reconstruction was carried out in all cases using a complete Memo 3D ring (Livanova PRT, London UK) (Figure 2).
The telephone interview was performed by cardiologists or cardiac surgeons in order to better identify and understand the possible complications, the physical status (NYHA class) and read directly or electronically the echocardiographic checks and clinical documents (e.g. hospital discharge letters) showed by the patients.