Commentary

This article by Yusuf et al. confirms, first of all, the renewed interest in repair of prolapse of the posterior leaflet. So far, because of the apparent simplicity of the surgical techniques (quadrangular resection, with or without sliding plasty and ring annuloplasty), and the excellent results obtained in expert centres, repair of the posterior leaflet has often been presented as a “straightforward” technique.
This article compares two surgical techniques for repairing posterior leaflet prolapse: the traditional quadrangular resection technique and repair without resection using PTFE neochordae to correct the prolapse. Long-term results of this “respect rather than resect approach” have been published [1]. A prospective randomized study comparing the two approaches has confirmed that preservation of leaflet tissue is associated with a significantly higher surface of coaptation [2]. It is worth noting that quadrangular resection, considered by many as the technique of choice to treat posterior leaflet prolapse, requires classically an annulus plication inducing
a deformation of the subvalvular region of the left ventricle. In contrast, triangular resection is not associated with this drawback and removes less normal tissue, and as a consequence, in my opinion, should be preferred.
Despite those standardized techniques showing excellent long-term results, mitral valve repair rates seem to be suboptimal even for prolapse of the posterior leaflet. In 2003
a European Survey from Iung et al. reported a 46.5% repair rate among patients operated on for mitral regurgitation, attributing this disappointing repair rate to “a lack of local competence” [3]. Whatever the reasons might be, one should not ignore the fact that prolapse of the posterior leaflet is not always anatomically simple, concerning only the middle portion of P2. On the contrary, there is a great variability in the location and the extent of the prolapsed area, which can make the repair difficult, especially if it involves one commissural area. Apart from the location and extent of the prolapsed area, the issue of the amount of leaflet tissue complicates even more the anatomical aspect of prolapse of the posterior leaflet. Degenerative mitral valve disease is often subdivided into two entities depending on the excess of tissue: fibroelastic deficiency, for which there is no excess of tissue, and the Barlow valve, for which there...


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