title: Commissural closure for the treatment of commissural mitral valve prolapse or flail.
abstract: OBJECTIVE
  Mitral regurgitation (MR) due to commissural prolapse/flail represents a challenging surgical problem for which a variety of reconstructive approaches have been proposed. The study aim was to report the authors' experience with commissural closure within such a difficult setting.
  
  
  METHODS
  Between 1998 and July 2007, a total of 115 patients (mean age 56.5 +/- 15.5 years) with MR due to pure commissural prolapse/flail of one or both leaflets underwent commissural closure associated with annuloplasty. The etiology of the disease was degenerative in 90.4% of cases and post-endocarditis in 9.6%. The commissural region involved by chordal rupture/elongation was the posterior-medial in 88 patients (76.5%) and the anterior-lateral in 27 (23.5%). The mean NYHA class was 1.9 +/- 0.8, and mean ejection fraction 58.2 +/- 7.7%.
  
  
  RESULTS
  There was one in-hospital death (0.9%). Among patients undergoing isolated mitral repair, the cardiopulmonary bypass and cross-clamp times were 58 +/- 11.6 min and 43 +/- 11.7 min, respectively. Actuarial survival at one and five years was 96.1 +/- 2.2% and 91 +/- 5.3%, respectively. At a mean follow up of 2.3 +/- 1.98 years (median 2.0; range: 1-8.3 years), two patients underwent mitral valve replacement for recurrence of severe MR. At the most recent echocardiographic study (performed in 108 patients), MR was absent in 60 patients (55.6%), mild in 43 (39.8%), moderate in three (2.8%) and severe in two (1.9%, both reoperated on). The mean mitral valve area was 2.8 +/- 0.63 cm2, and the mitral gradient 4.2 +/- 1.05 mmHg.
  
  
  CONCLUSIONS
  Commissural prolapse/flail of the mitral valve can be effectively corrected by suturing together the margins of the anterior and posterior leaflets in the commissural area. This type of repair is not time-consuming, and is easily reproducible and durable. In the authors' experience of this surgery, no signs of mitral stenosis were ever detected.
authors.affiliation: Department of Cardiac Surgery, San Raffaele University Hospital, Milan, Italy. lapenna.elisabetta@hsr.it
authors.forename: Elisabetta
authors.initials: E
authors.lastname: Lapenna
authors.forename: Michele
authors.initials: M
authors.lastname: De Bonis
authors.forename: Flavia
authors.initials: F
authors.lastname: Sorrentino
authors.forename: Giovanni
authors.initials: G
authors.lastname: La Canna
authors.forename: Antonio
authors.initials: A
authors.lastname: Grimaldi
authors.forename: Lucia
authors.initials: L
authors.lastname: Torracca
authors.forename: Francesco
authors.initials: F
authors.lastname: Maisano
authors.forename: Ottavio
authors.initials: O
authors.lastname: Alfieri
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D013504:Cardiovascular Surgical Procedures / Q000379:methods*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D008943:Mitral Valve / Q000601:surgery*; D008944:Mitral Valve Insufficiency / Q000601:surgery*; D008945:Mitral Valve Prolapse / Q000601:surgery*; D012189:Retrospective Studies; D016019:Survival Analysis; D016896:Treatment Outcome