title: A "Repair-All" Strategy for Degenerative Mitral Valve Disease Safely Minimizes Unnecessary Replacement.
abstract: BACKGROUND
  We examined the feasibility and efficacy of a "repair-all" strategy applied in all patients with degenerative mitral regurgitation, regardless of valve complexity, risk profile, and surgical approach.
  
  
  METHODS
  Between 2002 and 2011, 4,241 patients underwent mitral operations at our institution. Analysis was limited to 525 consecutive patients with mitral regurgitation due to leaflet prolapse (posterior, 75%; anterior, 5%; bileaflet, 20%) who underwent isolated mitral operations. A right minithoracotomy was used in 46% of procedures. Propensity scores identified 153 well-matched patient pairs for evaluation of the effect of surgical approach on valve reparability.
  
  
  RESULTS
  Mitral repair was successful in 99% (520 of 525) of patients. The location of the leaflet prolapse did not significantly influence the repair rate or the need for intraoperative revision of the initial repair. The repair rate and the need for intraoperative repair revision also did not significantly differ by surgical approach. Intraoperative revision did not confer a greater risk of perioperative morbidity or longer length of stay. At 8 years, freedom from severe mitral regurgitation was 97% ± 2%. Development of residual mitral regurgitation did not differ by location of the leaflet prolapse, need for repair revision, or surgical approach. After discharge, the survival trend did not differ between patients who did and did not require intraoperative repair revision.
  
  
  CONCLUSIONS
  In experienced centers, a "repair-all" strategy for degenerative mitral regurgitation can be used with nearly 100% repair rates and excellent outcomes, regardless of valve complexity. When necessary, intraoperative revision of the initial repair may be performed in most patients without a significant incremental risk, thereby further enhancing repair rates.
authors: Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California; Division of Cardiovascular Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
authors: Andrew B
authors: AB
authors: Goldstone
authors: Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California; Division of Cardiovascular Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
authors: Jeffrey E
authors: JE
authors: Cohen
authors: Division of Cardiovascular Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
authors: Jessica L
authors: JL
authors: Howard
authors: Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California.
authors: Bryan B
authors: BB
authors: Edwards
authors: Division of Cardiovascular Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
authors: Alexandra L
authors: AL
authors: Acker
authors: Division of Cardiovascular Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
authors: William
authors: W
authors: Hiesinger
authors: Division of Cardiovascular Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
authors: John W
authors: JW
authors: MacArthur
authors: Division of Cardiovascular Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
authors: Pavan
authors: P
authors: Atluri
authors: Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California. Electronic address: joswoo@stanford.edu.
authors: Y Joseph
authors: YJ
authors: Woo
mesh_terms: D004452:Echocardiography; D005260:Female; D005500:Follow-Up Studies; D019918:Heart Valve Prosthesis Implantation / Q000379:methods / Q000592:standards*; D006801:Humans; D008297:Male; D008875:Middle Aged; D008943:Mitral Valve / Q000601:surgery*; D008944:Mitral Valve Insufficiency / Q000000981:diagnostic imaging / Q000601:surgery*; D017410:Practice Guidelines as Topic; D012189:Retrospective Studies; D013997:Time Factors; D016896:Treatment Outcome; D019564:Unnecessary Procedures / Q000639:trends*