Saad Bader Zakai, Salman -Ur-Rehman Khan, Fazle Rabbi, Habiba Tasneem


Background: Convention mitral valve (MV) replacement is known to cause deterioration in the
left ventricle function, the major mechanism responsible being disruption of the annulo-papillary
continuity, thus favoring preservation of the mitral subvalvular apparatus. The aim of this study
was to compare the early and midterm results, in terms of cardiac mechanics and clinical
outcomes, of preserving the subvalvular apparatus (partial/complete) verses resection during
mitral valve replacement. Methods: This was a prospective non randomised trial. One hundred
and twenty-two patients (mean age 40.36±14.27 years) admitted for MV replacement from
January 2009 to September 2009 were included in the study. They were divided into 3 groups:
complete excision of the subvalvular apparatus (group 1=32); preservation of the posterior leaflet
(group 2=54) and total chordal preservation (group 3=36). Echocardiography was done
preoperatively, at discharge, and at 6 months follow-up. Results: The preservation groups 2, 3
revealed marked improvements with respect to the End-diestolic Volume (EDV) and End-Systolic
Volume (ESV) as compared to the non-preservation group 1 at discharge from hospital. At followup, the preservation groups showed improved EDV and ESV in contrast to the non-preservation
group, where the ventricular volumes had a declining pattern. Ejection fraction remained below
the baseline preoperative level in all three groups at discharge from hospital. In the follow-up,
chordal preservation groups showed significant improvements in the ejection fraction as compared
to the resection group. An interesting finding was that of PA pressures and LA size between the
groups. It was significantly improved in the preservation groups as compared to the resection
group. At follow-up, 43.5% of patients in group 1 were in AF compared with 27.5% in group 2
and 21.4% in group 3. More patients in group 1 were in NYHA functional class III or IV at
follow-up: 30.4% versus 7.5% and 7.1% respectively. Conclusion: Preservation of the mitral
subvalvular apparatus resulted in a greater decrease of ventricular dimensions at discharge which
was maintained at follow-up; complete resection resulted in ventricular dilatation at follow-up.
Furthermore, the ejection fraction improved in the preservation groups compared to the complete
resection group which showed a decline at follow-up.
Keywords: Mitral valve, MV preservation, MV replacement, chordal preservation, MV surgery,
subvalvular apparatus

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