Mitral valve reconstructive surgery: annuloplasty

Valve repair is currently considered as the elective surgical approach for mitral insufficiency when valve anatomy is appropriated. Mitral annuloplasty for degenerative disease provides the best results: hospital mortality < 1% and actuarial survival of 90 and 80% at 5 and 10-year followup, with most of patients free from reoperation and residual mitral regurgitation (90% freedom at 10-year). Valve repair in rheumatic disease has not so good results; although we have satisfactory results, other authors have reported a significantly higher need for reoperation due to mitral valve dysfunction. Valve dysfunction at 20-year was more common in patients younger than 20 years (26.8 vs. 4.5%). Congenital mitral valve disease is a heterogeneous group, so mitral annuloplasty must always be considered only as a part of valve repair, being necessary to correct the concomitant congenital anomalies. Hospital mortality varied from 1-10%, with a long-term reoperation rate for valve dysfunction of 20-50%, depending on the type of congenital valvular lesion. Valve repair in ischemic mitral regurgitation is still controversial due to its complex causal mechanisms. Mitral annuloplasty corrects valve regurgitation, only partially, by increasing valve coaptation, however it is not effective for the correction of geometrical changes in the leaflets and subvalvular apparatus motion. Restrictive annuloplasty is recommended, in order to increase valve coaptation. Recently, asymmetric annuloplasty rings are used to repair the abnormal postero-lateral valve region. Annu-loplasty for dilated cardiomyopathy and end-stage cardiac failure with severe mitral regurgitation, introduced by Bolling, has provided satisfactory results, with improvement in NYHA class, reduced hospitalization, and 1-year survival of 84%, although less than half of patient survived at 5-year. In conclusion, mitral annuloplasty should be considered as a part of the reconstructive surgery, being mandatory to individualize its use, so in each patient the "complete" valve reconstruction will require a different type of annuloplasty ring and concomitant repair techniques. We must avoid generalizing the surgical treatment as we have incorrectly done for years.