The evolution of reparative techniques for the mitral valve.

Forty-eight adult patients underwent mitral valve repair for nonischemic valvular incompetence between 1963 and 1981. Early in our experience, 21 individuals received wedge leaflet resection or leaflet plication with posteromedial commissural annuloplasty. More recently, midleaflet annuloplasty has been employed in 13 patients and is now our preferred technique. Operative mortality was 6.3%, and all deaths occurred prior to 1973. Eventually valve replacement was necessary in 10 patients; all replacements were done prior to 1977. Technical errors and progression of rheumatic disease each accounted for half of these replacements. Five-year survival by the life table method was 74 +/- 9% for the entire group. Survival at 5 years for patients with prolapsing leaflets was significantly better (87 +/- 7%) than for those with normal leaflet motion (46 +/- 14%). A residual postoperative murmur of mitral insufficiency correlated with the likelihood of subsequent valve replacement. Important technical aspects of valve repair are described, and criteria for optimal patient selection are discussed. The evolution of reparative methods has led to a better understanding and broader application of mitral valve reconstruction.