Respect Versus Resect Approaches for Mitral Valve Repair: A Meta-Analysis of Reconstructed Time-to-Event Data
2023; Elsevier BV; Volume: 213; Linguagem: Inglês
10.1016/j.amjcard.2023.12.010
ISSN1879-1913
AutoresTúlio Caldonazo, Michel Pompeu Sá, Xander Jacquemyn, Jef Van den Eynde, Hristo Kirov, Lamia Harik, Johannes C. Fischer, Dominique Vervoort, Johannes Bonatti, Ibrahim Sultan, Torsten Doenst,
Tópico(s)Cardiac Structural Anomalies and Repair
ResumoMitral valve repair (MVr) has been associated with superior long-term survival and freedom from valve-related complications compared with mitral valve replacement for primary mitral regurgitation (MR). The 2 main approaches for MVr are chordal replacement ("respect approach") and leaflet resection ("resect approach"). We performed a systematic review and a meta-analysis using 3 search databases to compare the long-term end points between both approaches. The primary end point was long-term survival. The secondary end points were long-term MR recurrence and reoperation. After reconstruction of time-to-event data for the individual survival analysis, pooled Kaplan–Meier curves for the end points were generated. A total of 14 studies (5,565 patients) were included in the analysis. The respect approach was associated with superior survival compared with the resect approach in the overall sample (hazard ratio [HR] 0.73, 95% confidence interval [CI] 0.56 to 0.96, p = 0.024, n = 3,901 patients) but not in the risk-adjusted sample (HR 1.00, 95% CI 0.55 to 1.82, p = 0.991, n = 620 patients). There was no difference between the approaches in the rate of MR recurrence in the overall sample (HR 1.39, 95% CI 0.92 to 2.08, p = 0.116, n = 1,882 patients) or in the risk-adjusted sample (HR 1.62, 95% CI 0.76 to 3.47, p = 0.211, n = 288 patients). The data for reoperation were only available in the overall sample and did not reveal a difference (HR 0.92, 95% CI 0.62 to 1.35, p = 0.663, n = 3,505 patients). In conclusion, the current evidence suggests no difference in long-term mortality, MR recurrence, or reoperation between the resect and respect approaches for MVr after adjusting for patient risk factors. More long-term follow-up data are warranted. Mitral valve repair (MVr) has been associated with superior long-term survival and freedom from valve-related complications compared with mitral valve replacement for primary mitral regurgitation (MR). The 2 main approaches for MVr are chordal replacement ("respect approach") and leaflet resection ("resect approach"). We performed a systematic review and a meta-analysis using 3 search databases to compare the long-term end points between both approaches. The primary end point was long-term survival. The secondary end points were long-term MR recurrence and reoperation. After reconstruction of time-to-event data for the individual survival analysis, pooled Kaplan–Meier curves for the end points were generated. A total of 14 studies (5,565 patients) were included in the analysis. The respect approach was associated with superior survival compared with the resect approach in the overall sample (hazard ratio [HR] 0.73, 95% confidence interval [CI] 0.56 to 0.96, p = 0.024, n = 3,901 patients) but not in the risk-adjusted sample (HR 1.00, 95% CI 0.55 to 1.82, p = 0.991, n = 620 patients). There was no difference between the approaches in the rate of MR recurrence in the overall sample (HR 1.39, 95% CI 0.92 to 2.08, p = 0.116, n = 1,882 patients) or in the risk-adjusted sample (HR 1.62, 95% CI 0.76 to 3.47, p = 0.211, n = 288 patients). The data for reoperation were only available in the overall sample and did not reveal a difference (HR 0.92, 95% CI 0.62 to 1.35, p = 0.663, n = 3,505 patients). In conclusion, the current evidence suggests no difference in long-term mortality, MR recurrence, or reoperation between the resect and respect approaches for MVr after adjusting for patient risk factors. More long-term follow-up data are warranted. Primary mitral valve regurgitation (MR) occurs in approximately 1% of the general population,1Wu S Chai A Arimie S Mehra A Clavijo L Matthews RV Shavelle DM. Incidence and treatment of severe primary mitral regurgitation in contemporary clinical practice.Cardiovasc Revasc Med. 2018; 19: 960-963Crossref PubMed Scopus (29) Google Scholar with prolapse of the posterior mitral leaflet accounting for the majority of cases.2El Sabbagh A Reddy YNV Nishimura RA Mitral valve regurgitation in the contemporary era: insights into diagnosis, management, and future directions.JACC Cardiovasc Imaging. 2018; 11: 628-643Crossref PubMed Scopus (138) Google Scholar Left untreated, severe MR carries an unfavorable prognosis, whereas surgical intervention offers the opportunity to address symptoms, reinstate quality of life, and improve overall survival.3Nishimura RA Vahanian A Eleid MF Mack MJ. Mitral valve disease–current management and future challenges.Lancet. 2016; 387: 1324-1334Abstract Full Text Full Text PDF PubMed Scopus (216) Google Scholar Owing to its demonstrably superior long-term survival and freedom from valve-related complications in comparison with mitral valve replacement, mitral valve repair (MVr) has been the recommended treatment in clinical guidelines.4Vahanian A Beyersdorf F Praz F Milojevic M Baldus S Bauersachs J Capodanno D Conradi L De Bonis M De Paulis R Delgado V Freemantle N Gilard M Haugaa KH Jeppsson A Jüni P Pierard L Prendergast BD Sádaba JR Tribouilloy C Wojakowski W ESC/EACTS Scientific Document Group2021 ESC/EACTS Guidelines for the management of valvular heart disease.Eur Heart J. 2022; 43: 561-632Crossref PubMed Scopus (1913) Google Scholar After MVr, the survival rates may even be equivalent to those of the general population.5Lazam S Vanoverschelde JL Tribouilloy C Grigioni F Suri RM Avierinos JF de Meester C Barbieri A Rusinaru D Russo A Pasquet A Michelena HI Huebner M Maalouf J Clavel MA Szymanski C Enriquez-Sarano M MIDA (Mitral Regurgitation International Database) InvestigatorsTwenty-year outcome after mitral repair versus replacement for severe degenerative mitral regurgitation: analysis of a large, prospective, multicenter, international registry.Circulation. 2017; 135: 410-422Crossref PubMed Scopus (219) Google Scholar, 6Sedrakyan A Vaccarino V Elefteriades JA Mattera JA Lin Z Roumanis SA Krumholz HM. Health related quality of life after mitral valve repairs and replacements.Qual Life Res. 2006; 15: 1153-1160Crossref PubMed Scopus (15) Google Scholar, 7Costa FDAD Colatusso DFF Martin GLDS Parra KCS Botta MC Balbi Filho EM Veloso M Miotto G Ferreira ADA Colatusso C Long-term results of mitral valve repair.Braz J Cardiovasc Surg. 2018; 33: 23-31PubMed Google Scholar The birth of leaflet resection ("resect approach"), characterized by the surgical excision of the diseased segment of the leaflet, followed by suturing of the remaining segments, traces back to Carpentier's pioneering work in 1983 and has since evolved into the gold standard for MVr.8Carpentier A. Cardiac valve surgery–the "French correction".J Thorac Cardiovasc Surg. 1983; 86: 323-337Abstract Full Text PDF PubMed Google Scholar Subsequent to this landmark development, multiple leaflet-preserving techniques ("respect approach") have emerged, aimed at optimizing coaptation while concurrently streamlining procedures to facilitate wider adoption, particularly, in the context of the growing trend in minimally invasive interventions.9Perier P Hohenberger W Lakew F Batz G Urbanski P Zacher M Diegeler A. Toward a new paradigm for the reconstruction of posterior leaflet prolapse: midterm results of the "respect rather than resect" approach.Ann Thorac Surg. 2008; 86: 718-725Abstract Full Text Full Text PDF PubMed Scopus (211) Google Scholar These respect techniques have in common the use artificial neochordae to suspend the prolapsed segments of the afflicted leaflet. Currently, the resect and respect approaches are firmly established as cornerstones of MVr, boasting exceptional long-term durability. Nevertheless, the discourse concerning nuanced distinctions between these approaches remains an ongoing and pertinent subject of investigation. A previously published meta-analysis summarizing the short-term end points of the respect and resect approaches suggested superior performance of the respect approach in terms of reduced operative mortality, diminished rates of permanent pacemaker implantation, and lower postoperative mean mitral valve gradients.10Sá MP Cavalcanti LRP Van den Eynde J Amabile A Escorel Neto AC Perazzo AM Weymann A Ruhparwar A Sicouri S Bisleri G Torregrossa G Geirsson A Ramlawi B Respect versus resect approaches for mitral valve repair: a study-level meta-analysis.Trends Cardiovasc Med. 2023; 33: 225-239Crossref PubMed Scopus (5) Google Scholar However, that meta-analysis only reported on short-term and perioperative end points. The present meta-analysis has the primary objective of discerning potential disparities between the respect and resect approaches with regard to long-term end points. In particular, our investigation scrutinized mortality rates and the maintenance of freedom from MR. By synthesizing and evaluating existing data, we aimed to provide a comprehensive assessment of the comparative efficacy and durability of these 2 pivotal techniques. Ethical approval of this analysis was not required because no human or animal subjects were involved. This review was registered with the National Institute for Health Research International Registry of Systematic Reviews. We performed a comprehensive literature search to identify contemporary studies reporting long-term end points in patients who underwent MVr with the 2 different techniques (respect or resect). The searches were run on January 2023 in the following databases: Ovid MEDLINE, EMBASE, and Coachrane Library. The search strategy for Ovid MEDLINE is listed in Supplementary Table 1. The study selection followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) strategy. After deduplication, the records were screened by 2 independent reviewers (TC and XJ). Any discrepancies and disagreements were resolved by a third author (MPS). Titles and abstracts were reviewed against the predefined inclusion and exclusion criteria. Studies were considered for inclusion if they reported direct end point comparisons between patients who underwent MVr with the 2 different techniques (respect or resect), with the results presented in Kaplan–Meier curves, which are required for digitization of data. Animal studies, abstracts, case reports, commentaries, editorials, expert opinions, conference presentations, and studies not reporting the end points of interest were excluded. The full text was pulled for the selected studies for a second round of eligibility screening. The references for articles selected were also reviewed for relevant studies not captured by the original search. The quality of the included studies was assessed using risk of bias assessment Newcastle–Ottawa scale for observational studies (Supplementary Table 2). A total of 2 reviewers (TC and XJ) independently performed data extraction. Accuracy was verified by a third author (MPS). The extracted variables included study characteristics (publication year, country, sample size, study design, and mean follow-up) and patient demographics (age, gender, diabetes, hypertension, chronic obstructive pulmonary disease, chronic kidney disease, previous stroke, coronary artery disease, and atrial fibrillation) and echocardiographic data (left atrial diameter, left ventricle end-diastolic volume, left ventricle end-systolic diameter, and mean left ventricular ejection fraction [LVEF]). The primary end point was long-term survival. The secondary end points were long-term MR recurrence and reoperation. We used the methods described by Guyot et al11Guyot P Ades AE Ouwens MJNM Welton NJ. Enhanced secondary analysis of survival data: reconstructing the data from published Kaplan-Meier survival curves.BMC Med Res Methodol. 2012; 12: 9Crossref PubMed Scopus (1289) Google Scholar and Wei et al12Wei Y Royston P. Reconstructing time-to-event data from published Kaplan-Meier curves.STATA J. 2017; 17: 786-802Crossref PubMed Scopus (154) Google Scholar to reconstruct individual patient data from the Kaplan–Meier curves of all eligible studies for the long-term end points. Raster and Vector images of the Kaplan–Meier curves were preprocessed and digitized so that the values reflecting to specific time points with their corresponding survival/MR recurrence/reoperation information could be extracted. Where additional information (e.g., number-at-risk tables or total number of events) were available, they were used to further calibrate the accuracy of the time to events.11Guyot P Ades AE Ouwens MJNM Welton NJ. Enhanced secondary analysis of survival data: reconstructing the data from published Kaplan-Meier survival curves.BMC Med Res Methodol. 2012; 12: 9Crossref PubMed Scopus (1289) Google Scholar,12Wei Y Royston P. Reconstructing time-to-event data from published Kaplan-Meier curves.STATA J. 2017; 17: 786-802Crossref PubMed Scopus (154) Google Scholar To confirm the quality of the timing of failure events captured, we thoroughly checked the consistency with the reported outcome data provided in the original publications. The Kaplan–Meier method was used to calculate the overall survival/MR recurrence/reoperation. The Cox proportional hazards regression model was used to assess the between-group differences. For these Cox models, the proportional hazards assumption was verified by plotting scaled Schoenfeld residuals, log–log survival plots, and predicted versus observed survival functions. We plotted the survival curves using the Kaplan–Meier product limit method and calculated the hazard ratios (HRs) and 95% confidence intervals (CIs) of each group. A total of 4,480 studies were retrieved from the systematic search, of which 14 met the criteria for inclusion in the final analysis. Figure 1 shows the PRISMA flowchart for the study selection. The included studies were published between 2010 and 2021. All studies were observational series, of which only 1 multicenter study and only 1 prospective study. A total of 3 studies originated from Germany; 2 from the Netherlands; 2 from Japan; and 1 each from Austria, China, Singapore, Sweden/Denmark (multicenter), Spain, and Saudi Arabia. Table 1 lists the details of the included studies. A total of 5,565 patients were included in the final analysis. The number of patients in each study ranged from 60 to 2,134, with a median of 201 patients (interquartile range 285). The mean weighted follow-up of the analysis was 65.1 months.Table 1Summary of included studies (references are in the supplementary material)AuthorYear of PublicationCountryN° of patientsRandomized, Multicentric, Prospective (Y/N)Mean follow-up (months)Bonaros2021Austria686 (393 respect, 255 resect)N, N, N80.4Wijnggaarden2021Netherlands125 (43 respect, 82 resect)N, N, N72Ma, 20212021China317 (243 respect, 74 resect)N, N, N82Sakaguchi2021Japan291 (125 respect, 166 resect)N, N, N32Centinkaya2020Germany721 (358 respect, 363 resect)N, N, NNRPfannmueller2020Germany2134 (1751 respect, 383 resect)N, N, N73.2Ma, 20192019China112 (33 respect, 79 resect)N, N, N26Tomsic2018Netherlands150 (51 respect, 99 resect)N, N, N52.8Chua2016Singapore202 (98 respect, 104 resect)N, N, N73.2Takai2016Japan106 (50 respect, 58 resect)N, N, N40 respect79 resectRagnarsson2014Sweden and Denmark201 (55 respect, 146 resect)N, Y, N70.8Silva2012Spain63 (28 respect, 35 resect)N, N, Y36Calafiore2011Saudi Arabia60 (39 respect, 21 resect)N, N, N36Lange2010Germany397 (192 respect, 205 resect)N, N, N22.8N = no; NR = not reported.; Y = yes. Open table in a new tab N = no; NR = not reported.; Y = yes. Supplementary Table 3 lists the demographic data of the patient population in each study. The mean age ranged from 50.2 to 64.4 years, the percentage of male patients ranged from 54.5% to 78.4%, the percentage of diabetes ranged from 0% to 8.9%, the percentage of hypertension ranged from 17.8% to 65.2%, the percentage of chronic obstructive pulmonary disease ranged from 1.3% to 17.9%, the percentage of chronic kidney disease ranged from 0% to 7.0%, the percentage of previous stroke ranged from 0% to 3.8%, the percentage of coronary artery disease ranged from 2.0% to 7.0%, and the percentage of atrial fibrillation ranged from 6.9% to 30.7%. Supplementary Table 4 lists the echocardiographic data of the patient population in each study. The mean left atrial diameter ranged from 44.0 to 54.8 mm, the mean left ventricle end-diastolic volume ranged from 52.7 to 69.0 mm, the mean left ventricle end-systolic diameter ranged from 32.6 to 56.0 mm, and the mean LVEF ranged from 53.0 to 67.7. Figure 2, Figure 3 show the pooled curves regarding survival, MR recurrence, and reoperation. The respect approach was associated with superior survival compared with the resect approach in the overall sample (HR 0.73, 95% CI 0.56 to 0.96, p = 0.024, based on 3,901 patients) (Figure 2) but not in the risk-adjusted sample (HR 1.00, 95% CI 0.55 to 1.82, p = 0.991, based on 620 patients) (Figure 3).Figure 3Pooled curves regarding long-term survival (A) and mitral regurgitation recurrence (B) in the risk-adjusted studies.View Large Image Figure ViewerDownload Hi-res image Download (PPT) There was no significant difference between both approaches for the rate of MR recurrence in either the overall sample (HR 1.39, 95% CI 0.92 to 2.08, p = 0.116, based on 1,882 patients) (Figure 2) or the risk-adjusted sample (HR 1.62, 95% CI 0.76 to 3.47, p = 0.211, based on 288 patients) (Figure 3). The data for reoperation were only available in the overall sample and did not reveal a significant difference (HR 0.92, 95% CI 0.62 to 1.35, p = 0.663, based on 3,505 patients) (Figure 2). In this meta-analysis including 14 comparative studies of MVr with the respect approach (neochordal replacement) versus the resect approach (leaflet resection), we demonstrated that the respect approach was associated with superior survival in the overall sample (HR 0.73 based on 3,901 patients) but not in the risk-adjusted sample (HR 1.00 based on 620 patients). We found no significant difference between approaches in terms of MR recurrence in either of the samples (HR 1.39 based on 1,882 patients; and HR 1.00 based on 288 patients). Data for reoperation were only available in the overall sample and did not reveal a significant difference (HR 0.92 based on 3,505 patients). Interestingly, our meta-analysis could demonstrate a significant survival difference in favor of the respect approach in the overall sample but not in the risk-adjusted sample. There are 3 hypotheses that could explain these findings: (1) the risk-adjusted sample was insufficiently powered to demonstrate a difference in survival between both techniques; (2) the confounders, that is, factors that increase the probabilities of the respect approach and mortality, have biased the results of the overall sample, or (3) there is a true survival advantage tied to the respect approach. Supporting the first hypothesis, the size of the risk-adjusted sample (i.e., 620 patients) was indeed considerably smaller than that of the overall sample (i.e., 3,901 patients). Furthermore, simple power calculations show that to demonstrate an effect size of HR 0.73 in Cox regression analysis with a power of 80%, a sample of approximately 2,100 patients would be required to demonstrate statistical significance, considering a mortality rate of 15% after 10 years of follow-up. It may, thus, be possible that simply a larger amount of data may be required to find a statistically and clinically significant result. In contrast, because a significant difference cannot be established with <2,100 patients, this already suggests that the absolute effect size (and thus incremental benefit for the population who underwent MVr) for any of these approaches will be rather small. Second, any effort to compare the respect versus resect approaches may be challenged by the presence of numerous potential confounders. In terms of patient characteristics, those who underwent the respect approach were more likely to be younger,13Lange R Guenther T Noebauer C Kiefer B Eichinger W Voss B Bauernschmitt R Tassani-Prell P Mazzitelli D. Chordal replacement versus quadrangular resection for repair of isolated posterior mitral leaflet prolapse.Ann Thorac Surg. 2010; 89: 1163-1170Abstract Full Text Full Text PDF PubMed Scopus (61) Google Scholar to be functioning in New York Heart Association classes I to II instead of III to IV,14Ragnarsson S Sjögren J Sanchez R Wierup P Nozohoor S. Polytetrafluoroethylene neochordae is noninferior to leaflet resection in repair of isolated posterior mitral leaflet prolapse: a multicentre study.Interact Cardiovasc Thorac Surg. 2014; 19: 577-583Crossref PubMed Scopus (19) Google Scholar,15Cetinkaya A Bär S Hein S Bramlage K Bramlage P Schönburg M Richter M. Mitral valve repair for posterior leaflet prolapse: long-term comparison of loop implantation vs resection.J Card Surg. 2020; 35: 11-20Crossref PubMed Scopus (7) Google Scholar and to have a lower serum creatinine.15Cetinkaya A Bär S Hein S Bramlage K Bramlage P Schönburg M Richter M. Mitral valve repair for posterior leaflet prolapse: long-term comparison of loop implantation vs resection.J Card Surg. 2020; 35: 11-20Crossref PubMed Scopus (7) Google Scholar Furthermore, they were less likely to have an LVEF <30% or previous cardiac surgery.16Pfannmueller B Misfeld M Verevkin A Garbade J Holzhey DM Davierwala P Seeburger J Noack T Borger MA. Loop neochord versus leaflet resection techniques for minimally invasive mitral valve repair: long-term results.Eur J Cardiothorac Surg. 2021; 59: 180-186Crossref PubMed Scopus (30) Google Scholar In contrast, patients who underwent the respect approach more commonly had arterial hypertension16Pfannmueller B Misfeld M Verevkin A Garbade J Holzhey DM Davierwala P Seeburger J Noack T Borger MA. Loop neochord versus leaflet resection techniques for minimally invasive mitral valve repair: long-term results.Eur J Cardiothorac Surg. 2021; 59: 180-186Crossref PubMed Scopus (30) Google Scholar and dyslipidemia.15Cetinkaya A Bär S Hein S Bramlage K Bramlage P Schönburg M Richter M. Mitral valve repair for posterior leaflet prolapse: long-term comparison of loop implantation vs resection.J Card Surg. 2020; 35: 11-20Crossref PubMed Scopus (7) Google Scholar,17Chua YL Pang PY Yap YP Abdul Salam ZH Chen YT Chordal Reconstruction versus Leaflet Resection for Repair of Degenerative Posterior mitral Leaflet prolapse.Ann Thorac Cardiovasc Surg. 2016; 22: 90-97Crossref PubMed Scopus (7) Google Scholar Despite these variations, it remains noteworthy that, collectively, they exhibited a lower EuroSCORE.15Cetinkaya A Bär S Hein S Bramlage K Bramlage P Schönburg M Richter M. Mitral valve repair for posterior leaflet prolapse: long-term comparison of loop implantation vs resection.J Card Surg. 2020; 35: 11-20Crossref PubMed Scopus (7) Google Scholar It is also likely that considerable bias exists in choosing the surgical technique based on mitral valve characteristics: patients with mitral valve leaflet flail, limited leaflet degeneration, limited mitral annular calcification, and, possibly, preserved secondary chordae were more likely to undergo chordal replacement (respect approach) than leaflet resection (resect approach).16Pfannmueller B Misfeld M Verevkin A Garbade J Holzhey DM Davierwala P Seeburger J Noack T Borger MA. Loop neochord versus leaflet resection techniques for minimally invasive mitral valve repair: long-term results.Eur J Cardiothorac Surg. 2021; 59: 180-186Crossref PubMed Scopus (30) Google Scholar,18Tomšič A Hiemstra YL van Brakel TJ Versteegh MI Ajmone Marsan N Klautz RJ Palmen M Excessive leaflet tissue in mitral valve repair for isolated posterior leaflet prolapse-leaflet resection or shortening neochords? A propensity score adjusted comparison.J Cardiovasc Surg (Torino). 2019; 60: 111-118PubMed Google Scholar,19van Wijngaarden AL Tomšič A Mertens BJA Fortuni F Delgado V Bax JJ Klautz RJM Marsan NA Palmen M. Mitral valve repair for isolated posterior mitral valve leaflet prolapse: the effect of respect and resect techniques on left ventricular function.J Thorac Cardiovasc Surg. 2022; 164: 1488-1497.e3Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar Pfannmueller et al16Pfannmueller B Misfeld M Verevkin A Garbade J Holzhey DM Davierwala P Seeburger J Noack T Borger MA. Loop neochord versus leaflet resection techniques for minimally invasive mitral valve repair: long-term results.Eur J Cardiothorac Surg. 2021; 59: 180-186Crossref PubMed Scopus (30) Google Scholar reported a higher proportion of anterior mitral leaflet prolapse and bileaflet prolapse in the respect group, which are anatomies that have proved difficult to manage using the leaflet resection but have become feasible with chordal replacement, reporting end points that do not differ from those with posterior mitral leaflet prolapse; of note, most other studies excluded anterior mitral leaflet prolapse and bileaflet prolapse from their analyses. Furthermore, patients in the respect group likely underwent operation at an earlier stage before the occurrence of severe atrial dilatation or atrial fibrillation, as suggested by smaller left atrial volumes and higher proportions of sinus rhythm in these patients.13Lange R Guenther T Noebauer C Kiefer B Eichinger W Voss B Bauernschmitt R Tassani-Prell P Mazzitelli D. Chordal replacement versus quadrangular resection for repair of isolated posterior mitral leaflet prolapse.Ann Thorac Surg. 2010; 89: 1163-1170Abstract Full Text Full Text PDF PubMed Scopus (61) Google Scholar,17Chua YL Pang PY Yap YP Abdul Salam ZH Chen YT Chordal Reconstruction versus Leaflet Resection for Repair of Degenerative Posterior mitral Leaflet prolapse.Ann Thorac Cardiovasc Surg. 2016; 22: 90-97Crossref PubMed Scopus (7) Google Scholar,19van Wijngaarden AL Tomšič A Mertens BJA Fortuni F Delgado V Bax JJ Klautz RJM Marsan NA Palmen M. Mitral valve repair for isolated posterior mitral valve leaflet prolapse: the effect of respect and resect techniques on left ventricular function.J Thorac Cardiovasc Surg. 2022; 164: 1488-1497.e3Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar The third hypothesis that there is a true survival advantage with the respect approach, of course, remains a possibility. In support of this, Pfannmueller et al,16Pfannmueller B Misfeld M Verevkin A Garbade J Holzhey DM Davierwala P Seeburger J Noack T Borger MA. Loop neochord versus leaflet resection techniques for minimally invasive mitral valve repair: long-term results.Eur J Cardiothorac Surg. 2021; 59: 180-186Crossref PubMed Scopus (30) Google Scholar notably the only study with a sample size above the critical power threshold of 2,100 (2,134 patients), did demonstrate a significantly lower overall mortality rate in the respect group (log-rank p = 0.003), despite long cardiopulmonary bypass times and more concomitant procedures. Although they did not perform propensity matching, they demonstrated that the survival difference remained significant even after correction for a number of covariates in multivariable Cox regression, including age, gender, arterial hypertension, myocardial infarction, LVEF, previous cardiac surgery, and concomitant tricuspid valve repair. The mechanism through which the respect approach may lead to improved survival is believed to be mainly related to hemodynamic advantages that will be discussed in the next section: lower postoperative MR grades, longer line of leaflet coaptation, larger implanted annuloplasty ring sizes, and lower transmitral gradients. Importantly, MR recurrence has previously been shown to be a significant independent predictor of mortality in MVr popluations.20Suri RM Clavel MA Schaff HV Michelena HI Huebner M Nishimura RA Enriquez-Sarano M. Effect of recurrent mitral regurgitation following degenerative mitral valve repair: long-term analysis of competing outcomes.J Am Coll Cardiol. 2016; 67: 488-498Crossref PubMed Scopus (183) Google Scholar An additional factor that could influence these findings of the surgeon preference, resulting in a classic treatment allocation bias. After the widespread adoption of Carpentier's leaflet resection technique, certain theoretical problems have arisen. Primarily, the crimping of the posterior part of the mitral valve annulus has raised potential issues concerning distortion of left ventricular morphology. Notably, investigations by David et al21David TE Omran A Armstrong S Sun Z Ivanov J. Long-term results of mitral valve repair for myxomatous disease with and without chordal replacement with expanded polytetrafluoroethylene sutures.J Thorac Cardiovasc Surg. 1998; 115: 1279-1286Abstract Full Text Full Text PDF PubMed Scopus (208) Google Scholar have highlighted that this effect is particularly pronounced when plicating more than 1.5 cm of the posterior annulus. Speculation has arisen that this phenomenon could adversely impact left ventricular systolic function. The initial support for this notion came from the study by Imasaka et al,22Imasaka K Tayama E Tomita Y. Left ventricular performance early after repair for posterior mitral leaflet prolapse: chordal replacement versus leaflet resection.J Thorac Cardiovasc Surg. 2015; 150: 538-545Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar which indicated lower LVEF at 1 month after MVr using the resect approach. Their suggestion was rooted in the superior preservation of the mitral-ventricular continuity. However, subsequent research by Wijngaarden et al19van Wijngaarden AL Tomšič A Mertens BJA Fortuni F Delgado V Bax JJ Klautz RJM Marsan NA Palmen M. Mitral valve repair for isolated posterior mitral valve leaflet prolapse: the effect of respect and resect techniques on left ventricular function.J Thorac Cardiovasc Surg. 2022; 164: 1488-1497.e3Abstract Full Text F
Referência(s)