title: Pseudoprolapse of the anterior leaflet in chronic ischemic mitral regurgitation: identification and repair.
abstract: OBJECTIVE
  Recurrence rates as high as 30% have been observed 6 months after treatment of chronic ischemic mitral regurgitation (CIMR) with isolated annuloplasty. We postulated that the high early recurrence rates resulted from the presence of untreated pseudoprolapse of the anterior leaflet.
  
  
  METHODS
  We conducted a retrospective study of all mitral valve repairs for CIMR performed by a single surgeon (S.W.H.) from 1995 to 2011. After annuloplasty, Gore-Tex neochordae were added if the high-pressure saline test indicated the presence of pseudoprolapse of the anterior leaflet.
  
  
  RESULTS
  A total of 47 patients underwent mitral valve repair for CIMR. Of the 47 patients, 24 (51%) were found to have pseudoprolapse requiring the addition of neochordae. For all patients, the average age was 65.1 years, and 65.2% were men. Fourteen (30%) had had a preoperative intra-aortic balloon pump placed by cardiologists. Fourteen (30%) had severe pulmonary hypertension. Concomitant coronary artery bypass grafting was performed in 40 patients, with an average of 2.2 grafts; 7 had previously undergone coronary artery bypass grafting. Mitral Carpentier-Edwards physio annuloplasty rings were used in all patients with a mean size of 29 mm. One patient died postoperatively. Follow-up data were available for all 47 patients at an average of 4.9 years. The 5-year survival rate was 82.5%. The mean pre- and postoperative New York Heart Association class, ejection fraction, and mitral regurgitation grade were 3 and 1.52 (P < .0001), 34% and 41% (P = .0006), and 3.51 and 1.08 (P < .0001), respectively. Two patients developed greater than moderate mitral regurgitation.
  
  
  CONCLUSIONS
  Effective repair of CIMR should include surgical techniques to correct pseudoprolapse of the anterior leaflet, when present. The selective addition of Gore-Tex neochordae to an undersized annuloplasty nearly eliminates recurrent regurgitation after mitral valve repair for CIMR.
authors: Section of Cardiac Surgery, Yale University School of Medicine, New Haven, CT 06520, USA. sabet.hashim@yale.edu
authors: Sabet W
authors: SW
authors: Hashim
authors: Samuel J
authors: SJ
authors: Youssef
authors: Bassem
authors: B
authors: Ayyash
authors: Anthony J
authors: AJ
authors: Rousou
authors: Sigurdur
authors: S
authors: Ragnarsson
authors: Susan
authors: S
authors: Collazo
authors: Arnar
authors: A
authors: Geirsson
mesh_terms: D000368:Aged; D002908:Chronic Disease; D003237:Connecticut; D001026:Coronary Artery Bypass; D017548:Echocardiography, Transesophageal; D005260:Female; D019918:Heart Valve Prosthesis Implantation / Q000009:adverse effects / Q000401:mortality; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008943:Mitral Valve / Q000000981:diagnostic imaging / Q000601:surgery*; D058386:Mitral Valve Annuloplasty / Q000009:adverse effects / Q000401:mortality; D008944:Mitral Valve Insufficiency / Q000000981:diagnostic imaging / Q000209:etiology / Q000401:mortality / Q000601:surgery*; D008945:Mitral Valve Prolapse / Q000000981:diagnostic imaging / Q000209:etiology / Q000401:mortality / Q000601:surgery*; D017202:Myocardial Ischemia / Q000150:complications*; D011237:Predictive Value of Tests; D012008:Recurrence; D012086:Reoperation; D012189:Retrospective Studies; D013997:Time Factors; D016896:Treatment Outcome