ࡱ> ILHU (bjbjnn .>aa PPPPPddddDd1)PPPP???((((((($*-(P?????(PPPP(?PPPP(?(&h$(P WQrP'()01)`').). $($().P8(d???????((???1)????).?????????R : EDITORIAL Respect or resect or resect with respect Titulo en espaol VOLKMAR FALK Prof. Dr. med. Volkmar Falk rztlicher Direktor Direktor der Klinik fr Herz-Thorax-Gefsschirurgie Deutsches Herzzentrum Berlin Augustenburger Platz 1 13353 Berlin e-mail:  HYPERLINK "mailto:falk@dhzb.de" falk@dhzb.de The art of mitral valve repair has constantly evolved over the past years. There is general agreement that independent of the chosen technique for mitral repair, a perfect result includes a line of copatation below the annulus, an at least 2/3 anterior leaflet to 1/3 posterior leaflet ratio, sufficient coaptation length (6-8mm), and a geometric remodeling of the mitral annulus by means of an annuloplasty without causing any inflow gradient. In order to achieve these goals prolapsing leaflet segments need to be shortended in height by either resection techniques or by placing artificial chordae. Both approaches can yield excellent short and long-term outcomes if performed in expert centers as is once more demonstrated by the elegant paper of Domenech et al in this issue of the Journal. (1) Among the potential disadvantages of the resection technique are: impaired leaflet mobility (in extensive resection the posterior leaflet is shortended, largely immobile and the valve often has the appearance of a monocusp valve), limited depth of coaptation (due to removal of tissue), and a change in the annular geometry of the posterior annulus (especially with quadrangular resections without sliding plasty). In contrary, the respect technique according to Patrick Perrier, who pioneered this concept, serves the aim of transforming the posterior leaflet into a smooth, regular, and vertical buttress parallel to the posterior wall of the left ventricle against which the anterior leaflet will come in apposition. (2) In an experimental set-up Padala et al. have shown that a complete restoration of normal coaptation length is only possible with a chordal replacement technique. (3) Larger coaptation length has also been shown clinically both in short- and long-term observations. (4,5) Due to unrestricted leaflet mobility and enough redundant tissue, there is less of a tendency to downsize the annuloplasty ring. Seeburger (4) as well as Lange (5) have shown that with a respect technique larger ring sizes are implanted as compared to the resect technique. As a result, the remaining valve orifice is larger and the mean gradient across the repaired mitral valve may be lower. (4) While at rest the observed differences may not be clinically important, they may become relevant under exercise conditions. Systematic analyses are unfortunately lacking. Interestingly, chordal replacement may in addition offer better ventriculo-arterial coupling and left ventricular performance (6). In a meta-analysis of 8 studies comprising 1922 patients at a mean follow up of 2.9+/-2.8 years chordal replacement for P2 prolapse was associated with a significantly larger mitral valve orifice area, a lower trans-mitral gradient and lower risk of reoperation, as compared to P2-resection. There was however no difference in operative mortality or complications. (7) The series by Domenech et al. (1) has to be interpreted along these lines. They found no difference in terms of mortality, freedom from reoperation and freedom from significant MR for both techniques. The groups were however quite different with respect to the underlying pathology with more complex disease in the chordal replacement group. 92% of patients had a posterior prolapse in the resect group, as compared to only 65% in the chordal replacement group. 34 % of the patients in the latter had either anterior or bi-leaflet prolapse. One could therefore argue that a similar outcome with regard to the freedom from reoperation and the recurrence of severe MR despite a more challenging pathology in the chordal replacement group would in principal support the concept of respect rather than resect. One additional advantage of the chordal replacement technique is that corrective means are optional should the initial result of the repair show residual mitral insufficiency or prolapse. After resection and without any redundant tissue left, the options of re-repairing the valve either immediately or late during follow-up are limited. In the same issue of the Journal, Guillermo et al present their initial series with the use of premeasured PTFE-loops for chordal replacement in mitral valve repair. (8) This technique which has simplified the use of neochordae and avoids the problem of unintended shortening of artificial chords during knot-tying can be easily adopted and yields excellent results. Interestingly they have combined neochords for repair of the anterior and a resection technique for repair of the posterior leaflet, a technique that is particular useful in cases of Barlow-disease with excessive redundant leaflet tissue. This combined approach illustrates once more that being undogmatic but flexible is the key for success in mitral valve repair. Transapical beating heart techniques for chordal replacement are currently evaluated in clinical trials and may soon become an alternative to the current repair standard which is minimally invasive mitral valve repair. (9) As for now, multiple surgical repair techniques for type II mitral valve pathologies are at our hands. Whatever technique we chose, we should keep in mind how the godfather of mitral valve repair, Alain Carpentier, valued a good repair: In the end, the valve has to smile at you. REV ARGENT CARDIOL 2019;87:XXX-XXX. http./dx.doi.org/10.7775/rac.v87.i3. VER ARTCULOS RELACIONADOS: Rev Argent Cardiol 2019;87:xxx-xxx. http://dx.doi.org/10.7775/rac.v87.i3.13806 y Rev Argent Cardiol 2019;87:xxx-xxx. http://dx.doi.org/10.7775/rac.v87.i3.14330 REFERENCES Domenech A, Marchenchino RG, Posatini R, Fortunato GR, Rossi E, Kotowicz V. Leaflet Resection versus Chordal Replacement for Degenerative MitralRegurgitation: Long-term Outcomes According to the Technique Used. Rev Argent Cardiol 2019;XX:XXX-XXX. Perier P, Hohenberger W, Lakew F, Batz G, Urbanski P, Zacher M, et al. Toward a new paradigm for the reconstruction of posterior leaflet prolapse: midterm results of the "respect rather than resect" approach. Ann Thorac Surg 2008;86:718-25.  HYPERLINK "http://doi.org/dgwq59" http://doi.org/dgwq59 Padala M, Powell SN, Croft LR, Thourani VH, Yoganathan AP, Adams DH. Mitral valve hemodynamics after repair of acute posterior leaflet prolapse: quadrangular resection versus triangular resection versus neochordoplasty. J Thorac Cardiovasc Surg. 2009;138:309-15.  HYPERLINK "http://doi.org/crn9v2" http://doi.org/crn9v2 Seeburger J, Falk V, Borger MA, Passage J, Walther T, Doll N, et al. Chordae replacement versus resection for repair of isolated posterior mitral leaflet prolapse: galit. Ann Thorac Surg 2009;87:1715-20.  HYPERLINK "http://doi.org/bkszfq" http://doi.org/bkszfq Lange R, Guenther T, Noebauer C, Kiefer B, Eichinger W, Voss B, et al. Chordal replacement versus quadrangular resection for repair of isolated posterior mitral leaflet prolapse. Ann Thorac Surg 2010;89:1163-70.  HYPERLINK "http://doi.org/dnhzvz" http://doi.org/dnhzvz Imasaka 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;150:538-45.  HYPERLINK "http://doi.org/f7p84b" http://doi.org/f7p84b Mazine A, Firedrich J, Nedadur R, Verma S, Ouzounian M, Jni P, et al. Systematic review and meta-analysis of chordal replacement versus leaflet resection for posterior mitral leaflet prolapse. J Thorac Cardiovasc Surg 2018;155:120-8.  HYPERLINK "http://doi.org/gcwkzx" http://doi.org/gcwkzx Guillermo N, Vaccarino GN, Gutirrez G, Gil C, Bastianelli G, Melchiori R, et al. Initial Single-center Experience with Premeasured Chordal Loops for Mitral Valve Repair. Rev Argent Cardiol 2019;87:XXX-XXX. Colli A, Manzan E, Aidietis A, Rucinskas K, Bizzotto E, Besola L, et al. An early European experience with transapical off-pump mitral valve repair with NeoChord implantation. Eur J Cardiothorac Surg 2018;54:460-6.  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Trebuchet MSO FrutigerLTStd-Light7.*{$ CalibriA$BCambria Math"q;v;v;;!20x x  KQHP  $P' a2!xxQN Falk, Prof. Dr. med. VolkmarArea de Revista      Oh+'0 $ D P \hpx Falk, Prof. Dr. med. VolkmarNormalArea de Revista2Microsoft Office Word@@V@V ՜.+,D՜.+,H hp|  ;x   TtuloTitelD 8@ _PID_HLINKSA0#7http://doi.org/c6zfDhttp://doi.org/gcwkzx http://doi.org/f7p84bT http://doi.org/dnhzvzY http://doi.org/bkszfq^Uhttp://doi.org/crn9v2http://doi.org/dgwq59pFmailto:falk@dhzb.de !"#$%&'()*+,-./012345679:;<=>?ABCDEFGJKNRoot Entry F@  WM@1Table I.WordDocument .>SummaryInformation(8DocumentSummaryInformation8@MsoDataStore W WPIKECAXRLR==2 W WItem 2PropertiesUCompObj v   F$Documento de Microsoft Word 97-2003 MSWordDocWord.Document.89q Respect or resect or resect with respect - Archivo PPCT

Respect or resect or resect with respect;
Respectar o resecar o resecar con respeto

Creators:Falk, Volmark
2019-06-19

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Metadatos destacados

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Argentine Journal of Cardiology

Editor

Sociedad Argentina de Cardiología

Fuente

Revista Argentina de Cardiología; Vol 87, No 3 (2019); 183-184, Argentine Journal of Cardiology; Vol 87, No 3 (2019); 183-184

Citación

Falk, Volmark, “Respect or resect or resect with respect,” Archivo PPCT, consulta 2 de abril de 2026, http://archivoppct.caicyt.gov.ar/items/show/9600.

Dublin Core

Autor

Falk, Volmark

Fuente

Revista Argentina de Cardiología; Vol 87, No 3 (2019); 183-184
Argentine Journal of Cardiology; Vol 87, No 3 (2019); 183-184

Editor

Sociedad Argentina de Cardiología

Fecha

2019-06-19

Derechos

Los que firman al pié, certificamos que tenemos total responsabilidad por la conducción de este estudio y por el diseño y la interpretación de los datos. Nosotros escribimos el manuscrito y somos responsables por la decisión acerca del mismo. Cada uno de nosotros cumple la definición de autor como se afirma en el Comité Internacional de Editores de Revistas Médicas (International Committee of Medical Journal Editors, ver www.icmje.org). Nosotros hemos visto y aprobado el manuscrito final. Ni el artículo, ni ninguna parte esencial del mismo, incluido las tablas y las figuras, será publicado o admitido para arbitrar a otra parte antes de aparecer en la Revista.También notificamos haber leído la sección “conflicto de intereses”, y revelaríamos cualquiera que existiera. Dejamos constancia que si nuestro artículo se publicara en la RAC, cederíamos los derechos (copyright) a la Revista.Los documentos publicados en esta revista están bajo la licencia Creative Commons Atribución-NoComercial-Compartir-Igual 2.5 Argentina.
Those signing below certify that we have full responsibility for the conduction of this study and for the design and interpretation of the information. We wrote the manuscript and are responsible for its decision. Each of us fulfills the definition of authorship as stated by the International Committee of Medical Journal Editors ( www.icmje.org). We have signed and approved the final manuscript. Neither the manuscript, nor any essential part thereof, including tables and figures, will be published or accepted for refereeing elsewhere before being published in the Journal. We have also read the "Conflict of Interest" section and would disclose any existing. We state that if our manuscript is published in the RAC, we shall transfer the copyright to the Journal.

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eng
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info:eu-repo/semantics/publishedVersion