Associazione Nazionale Medici Cardiologi Ospedalieri



How to manage mitral valve posterior leaflet hypoplasia

Fiorentino Mariafrancesca Cotignola(Ravenna) – Maria Cecilia Hospital GVM | Mikus Elisa Cotignola(Ravenna) – Maria Cecilia Hospital GVM | Costantino Antonino Cotignola(Ravenna) – Maria Cecilia Hospital GVM

Background: Mitral valve posterior leaflet hypoplasia is a relatively rare and often congenital anatomical malformation. In this condition, achieving a good and durable mitral valve repair still represents a challenge for surgeons

Methods: We present the case of a 43 years old man presenting with exertional dyspnoea due to severe mitral regurgitation. Transthoracic and transesophageal echocardiograms revealed a severe hypoplasia of the posterior mitral leaflet with an significant prolapse of the anterior leaflet (particularly A2-A3), which determined massive regurgitation. The anteroposterior annular diameter was 38 mm with a 4 mm mitro-anular disjunction, left ventricular telediastolic diameter was 59 mm and ejection fraction 68%. No other cardiac malformations were evident; in particular tricuspid valve was normal.

Results: Surgery was performed through a right mini-thoracotomy with femoral cannulation, using three-dimensional video-assisted technology. The mitral valve was approached from the left atrium, behind the interatrial groove. Surgical inspection revealed a severely hypoplasic posterior leaflet and a wide anterior leaflet prolapsing near the postero-medial commissure (A2-A3) (Figure 1). Based on our previous experience, we decided to repair the valve performing a posterior para-commissural edge-to-edge (A3-P3) followed by an atypical annuloplasty using a bovine pericardium band, shaped on a 40 mm ring sizer, only in the postero-medial portion of the mitral annulus (Figure 2). On the hydrostatic test, the valve showed a satisfactory continence, that was confirmed on the intraoperative TEE. Postoperative course was uneventful and the patient was discharged home on postoperative day 7. Transthoracic echocardiography at discharge showed a good result of the mitral valve repair with no residual regurgitation a medium gradient across the mitral valve of 3 mmHg.

Conclusions: In our experience, reductive annuloplasty ‘t the optimal treatment for hypoplasic mitral valve posterior leaflet because it lowers the already small posterior leaflet, thus reducing the coaptation surface. To avoid this, we introduced this technique that improved our surgical outcomes.