A report on the successful rescue of the entire anterior mitral leaflet through the implementation of a bespoke procedure in the context of mitral valve replacement

A report on the successful rescue of the entire anterior mitral leaflet through the implementation of a bespoke procedure in the context of mitral valve replacement | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article A report on the successful rescue of the entire anterior mitral leaflet through the implementation of a bespoke procedure in the context of mitral valve replacement Francesco Nappi, Ibrahim Abdou, Antonio Salsano, Ivancarmine Gambardella, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6738874/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 02 Mar, 2026 Read the published version in Journal of Cardiothoracic Surgery → Version 1 posted 10 You are reading this latest preprint version Abstract Background: A bespoke procedure for the replacement of the mitral valve (MV) was devised, with the aim of preserving the rescued anterior mitral leaflet (AML). The approach employed involved the implementation of a full chordal-rescue mitral valve replacement (FCR-MVRpl), with the objective of preserving the anatomical configuration of the left ventricle. This technique has been shown to be beneficial for patients suffering from various forms of MV disease, including functional, degenerative, and infectious MV disease, who were previously unable to undergo MV repair. The investigation aimed to determine whether the technique caused procedural complications and if so, whether these resulted in left ventricular (LV) remodelling and how it affected survival rates. Methods: The study population comprised 161 patients, of whom 94 (57.1%) had degenerative mitral valve disease, 58 (36.0%) had functional mitral valve disease, 9 (5.6%) had infective mitral valve disease, and 2 (1.2%) had rheumatic mitral valve disease. In the 93 patients diagnosed with complicated MV disease, massive calcification was observed in 59 cases (36.6%), while 25 (15.5%) cases demonstrated mitral annular disjunction (MAD) and 9 (5.6%) cases presented with endocarditis and posterior annular abscesses. The anterior leaflet was completely rescued and then dislocated from its attachment to the annulus, a condition spanning from the posterior commissure to the anterior commissure. In cases involving excess tissue, a segment of the free edge of the translocated leaflet had to be excised, ensuring the preservation of a small section of the edge and the entire chordae tendineae unit. Results: Within 12 months following FCR-MVRpl, 2 patients (1.2%) experienced procedural-related complications. The freedom from procedural-related complications after FCR-MVRpl was 98.6 ± 0.97% at 12 months after surgery. The 1-year freedom from re-hospitalisation for heart failure was 94.2% ± 1.9%. Multivariable Cox analysis revealed a trend towards higher risk of treatment failure in patients who had a preoperative lower rate of LVEF (hazard ratio: 0.95; 95% CI: 0.92 to 0.99; p = 0.015 by the log-rank test). With the exception of patients who did not reach 12 months of follow-up, 11 (8.0%) patients exhibited a deterioration in their New York Heart Association (NYHA) functional class. However, most patients showed clinical benefits following FCR-MVRpl. Indeed, 112 patients (81.2%) were classified into NYHA Class I. Conclusion: The FCR-MVRpl is considered both safe and effective for a variety of cases without procedural-related complications. This technique preserves the left ventricle from dilatation and is beneficial for patients unable to undergo MV repair. The AML is used to treat severe cases of calcified posterior mitral annulus, complicated Barlow disease and endocarditis involving the posterior annulus. The FCR-MVRpl is not recommended for cases of severe complete MV calcification. mitral valve (MV) mitral valve replacement (MVR) chordal preservation chordal sparing Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 1. Introduction It has been demonstrated in both experimental and clinical studies that it is of significant importance to maintain the integrity of the subvalvular apparatus during the process of mitral valve replacement (MVR) [ 1 – 4 ]. This was accomplished through an examination of the influence exerted on ventricular functionality as a consequence of partial [ 3 – 5 ] or total [ 6 ] surgical sparring of the mitral valve apparatus. Additionally, the utilization of Gore-Tex sutures (W. L. Gore, Flagstaff, AZ) was employed with the objective of guaranteeing uninterrupted continuity between the mitral annulus and the papillary muscles (PMs) [ 7 – 9 ]. The following report delineates the methodology we have devised to maintain the subvalvular apparatus of the mitral valve (MV) in a manner that is both physiological and anatomical. The surgical technique under consideration involves the transection of the entire anterior mitral leaflet (AML), thereby facilitating a comprehensive full chordal rescue mitral valve replacement (FCR-MVRpl) ( Fig. 1A–E) . This procedure is predicated on three fundamental tenets. Firstly, a sufficient amount of surrounding tissue must be removed in order to facilitate the successful implantation of an adequately sized valve. Secondly, it is essential that no interference occurs with the functionality of the prosthetic valve due to the preserved structure. Thirdly, it is imperative to avoid the formation of any obstruction within the left ventricular outflow tract. 2. Methods The study was granted ethical approval by the institutional review board of University of Montpellier (IRB reference number No. UM 2023-010, May 17) and the requirement for individual patient consent was waived. A retrospective review was conducted on a prospectively maintained database of patients who underwent surgical treatment for MV disease between 2014 and 2023. This repository of data is subject to continuous updates and maintenance by clinical information experts. The data collection process is subjected to regular validation through both internal and external control mechanisms. Variables pertaining to the preoperative and postoperative periods are entered prospectively during the course of the patient’s hospitalization, while follow-up data are entered at subsequent encounters. Updates to follow-up data pertaining to survival and reintervention were conducted through a review of the electronic medical record, communication with referring medical practitioners, or direct engagement with patients and their families. Prior to the commencement of statistical analysis, the French national mortality database ( https://www.insee.fr ) was consulted in order to ascertain the most recent data available at the time of the data freeze. The primary safety endpoint was defined as the absence of procedural-related complications within 12 months. A procedural-related complication was defined as follows: any occurrence necessitating undersizing of the mitral prosthetic, resulting in patient-prosthesis mismatch; absence of the interference of the implanted prosthetic valve by the preserved valvular and subvalvular structure; absence of left ventricular outflow tract (LVOT) obstruction; structural/nonstructural valve deterioration (SVD/NSVD); and cardiac rupture. SVD was defined according to the recent consensus statement from the European Association of Percutaneous Cardiovascular Interventions. The aforementioned statement posits a distinction between hemodynamic and morphological SVD [ 10 ]. Secondary endpoints encompassed death, the mean percentage change in left ventricular end-diastolic dimensions index (LVEDDI), a worsened New York Heart Association (NYHA) class or rehospitalisation for heart failure within 12 months, in addition to mitral prosthesis dysfunction, including prosthesis regurgitation grade and thrombosis requiring reoperation. Furthermore, treatment failure was identified as a composite endpoint (CEP) at 12 months, characterised by the occurrence of death, mitral valve reoperation, or recurrence of moderate or severe mitral prosthesis dysfunction. A sternotomy was performed on all patients. The procedure employs standard bicaval cannulation, whereby exposure of the valve is achieved via a transatrial incision, as previously described by Guiraudon et al. [ 11 ]. A standard normothermic (36 ℃) cardiopulmonary bypass was employed for the purpose of myocardial protection. The cardioplegia used was either antegrade intermittent warm potassium-rich or both antegrade and retrograde warm potassium-rich. The latter was used in patients requiring procedures associated with prolonged cardiopulmonary bypass. For patients who require systemic cooling, warming was achieved by maintaining a 10 ℃ temperature difference between core blood and internal temperature during surgical hemostasis. Cardiopulmonary bypass was stopped once the body temperature reached 36 ℃. In instances where the valve was deemed irreparable following preoperative echocardiography and in situ exploration of the MV lesion, the AML was detached from the annulus between the two commissures (Fig. 1A,B). Upon full mobilisation, the AML was accompanied by its complete subvalvular apparatus, which consisted of between four and six equally distributed chords for each papillary muscle (Fig. 2B). In the treatment of patients diagnosed with Barlow’s disease and bivalvular prolapse, the excision of 3–5 mm of excess tissue (Fig. 2B) may significantly reduce the risk of excessive neocollagenisation of the bioprosthesis stent, with the potential for involvement of the leaflets and subsequent development of secondary stenosis. Furthermore, the removal of excess valvular tissue is an effective procedure to mitigate the risk of LVOT obstruction (Fig. 2A,B). The subsequent step involves the reattachment of the AML to the posterior leaflet and annulus, which occurs in the corresponding location with the prothesis valve sutures, as illustrated in Fig. 1C. It is noteworthy that the normal geometry is likely to be maintained with greater efficacy in cases wherein the anterior leaflet has not been subdivided [ 12 , 13 ]. The utilization of FCR-MVRpl is contraindicated in instances of substantial thickening or calcification in either the AML or the annulus, necessitating the implementation of alternative measures. The procedure of elliptic excision of tissue will not be carried out if, upon examination, the AML is found to be relatively uncompromised, as previously described by Sintek and colleagues [ 9 ]. Consequently, the leaflet tissue with the primary chordae must not be reattached to the anterior annulus using mattress sutures, which are subsequently employed for prosthetic valve implantation. The entire mitral annulus is to be in contact with the mitral prostheses (Fig. 1D,E). In certain instances, the redundant and excessive tissue cannot be excised and is instead employed for the repair of the mitral annular disjunction (MAD), when it occurs in conjunction with degenerative mitral valve disease, or sutured on the atrial side of the annulus in patients with mitral annular calcification (MAC), prior to the tying of prosthetic valve sutures. A 4 − 0 Prolene suture (Ethicon, Sommerville, NJ, USA) is used for two purposes in the attachment of markedly redundant tissue to the left atrial endocardium. First, it serves to reinforce the posterior mitral annulus. Second, it is employed to prevent the redundant tissue from AML from extending over the sewing ring. The complete mobilisation of the AML and its insertion into the posterior annulus and prosthetic valve (Fig. 1C–E) will prevent any protrusion into the LVOT or interference with prosthetic valve function (Fig. 1D,E). The double valve procedure (aortic and mitral) has afforded the chance to visually inspect the left ventricular chamber via the open aorta, enabling observation of retained AML structures within the LVOT. Obstruction is effectively avoided through AML translocation, although issues can arise when excessive AML tissue is retained post-partition three and four on the mitral annulus’s aortic aspect [ 9 , 14 ]. The PML, when sufficiently pliable, can typically be maintained in situ with the attached chordae. Excessive redundancy in the leaflet tissue is folded into the annulus and advanced to the leading edge of the leaflet tissue. Conversely, in the event of extensive redundancy, thickening, and fibrosis of the PML, a small wedge resection is performed to facilitate the implantation of a larger prosthetic. In cases where patients present with infective endocarditis (IE) involving multiple infected leaflets and poor annular consistency, surgical repair is not recommended. Therefore, the recommended surgical approach is concomitant mitral valve replacement, utilising a conventional stented xenograft or mechanical prosthesis. In such cases, the translocated tissue of the AML can be employed in the repair of abscess formation on the posterior annulus. In cases necessitating comprehensive repair of the posterior mitral annulus due to IE, the entire AML with its chordal apparatus is employed for annular reconstruction. It is recommended that mitral valve annulus reconstruction be performed prior to the insertion of prostheses, using the AML, which should be sutured with 4 − 0 polypropylene. The relocation of the rescued AML can result in the formation of a properly neoannulus, which serves to prevent the dangerous decalcification of the native annulus in patients presenting with massive posterior MAC, with or without MAD. In the event that the leaflet tissue is of sufficient consistency, the AML can be sutured over the PML. Alternatively, sutures can be passed from the left atrium around the retracted mitral annulus directly over the AML, encasing the prosthetic valve stent. This technique serves to reduce the potential for traction between the calcific annulus, PML, and subvalvular apparatus, thereby avoiding the strain that would otherwise be placed on fragile structures. Patients with diffuse myxomatous degeneration have been observed to exhibit an abnormal systolic superior shift of the papillary muscles, accompanied by traction. Although there is likely a relationship between abnormal papillary muscle mechanical motion and MAD, further investigations are required to determine the optimal surgical approach to avoid deleterious complications. 3. Statistical Analysis Categorical data are presented as frequencies and percentages in text and tables, with Fisher’s exact test or the chi-square test used as appropriate. The normality criteria were met for each continuous variable. For normally distributed data, independent sample or paired sample t-tests were employed, with mean ± standard deviation or median and interquartile range presented in text and tables. The development of event-free survival curves was facilitated through the implementation of the Kaplan–Meier method. In order to account for the presumed correlation with treatment failure, a multivariable model was performed, incorporating baseline age, gender, diabetes, left ventricular ejection fraction (LVEF), and severity of mitral regurgitation (MR). Treatment effects were estimated as hazard ratios with 95% confidence intervals. Derivation of these intervals utilised the Cox proportional hazards model, whilst the proportional hazards assumption was assessed via a graphical method. A p value less than 0.05 was designated as statistically significant. The analyses were conducted utilising R statistical software, version 4.3.1 (R Foundation for Statistical Computing, Vienna, Austria). 4. Results The present study was conducted between January 2014 and November 2023, and its primary objective was to investigate the outcomes of FCR-MVRpl using the AML translocation, with a particular focus on the incidence of adverse events. Indications for FCR-MVRpl included degenerative valve disease in 58.4% of cases (94 patients), functional MR in 36.0% (58 patients), and infective endocarditis in 5.6% (9 patients). The mean age of subjects undergoing FCR-MVRpl was recorded as 72.52 years, with a standard deviation of ± 10.36 years. The most common underlying cause of functional mitral regurgitation was secondary ischemic MR in 72.4% of cases. Furthermore, it is notable that MAD occurred in 15.5% of patients, and 36.6% presented with severe mitral valve calcification. The baseline characteristics of the entire patient population are delineated in Table 1 . As illustrated in Fig. 3 , the flow chart is presented. Table 1 Baseline characteristics of the overall patient population (n = 161). Clinical characteristics Degenerative MR (n = 94) Endocarditis (n = 9) Functional MR (n = 58) p value Age (years), (median [IQR]) 74.00 [69.00, 80.00] 73.00 [61.00, 82.00] 71.50 [67.00, 78.00] 0.35 Female, n (%) 45 (47.9) 5 (55.6) 22 (37.9) 0.39 BMI, mean ± SD 26.29 ± 5.42 24.66 ± 3.29 25.58 ± 4.99 0.54 BSA, mean ± SD 1.83 ± 0.22 1.79 ± 0.14 1.81 ± 0.23 0.85 Hypertension, n (%) 53 (56.4) 5 (55.6) 34 (58.6) 0.96 Smoke, n (%) 27 (28.7) 3 (33.3) 23 (39.7) 0.38 Diabetes, n (%) 16 (17.0) 3 (33.3) 27 (46.6) < 0.001 Hypercholesterolemia, n (%) 29 (30.9) 4 (44.4) 35 (60.3) 0.002 CAD, n (%) 17 (18.1) 2 (22.2) 40 (69.0) < 0.001 AMI, n (%) 2 (2.1) 1 (11.1) 33 (56.9) < 0.001 Previous cardiac surgery, n (%) 6 (6.4) 3 (33.3) 12 (20.7) 0.007 Previous CABG, n (%) 0 (0.0) 1 (11.1) 4 (6.9) 0.02 Peripheral vascular disease, n (%) 10 (10.6) 0 (0.0) 4 (6.9) 0.46 COPD, n (%) 6 (6.4) 0 (0.0) 3 (5.2) 0.72 Atrial fibrillation, n (%) 40 (42.6) 2 (22.2) 31 (53.4) 0.15 Definitive PMK, n (%) 3 (3.2) 1 (11.1) 7 (12.1) 0.19 Stroke, n (%) 5 (5.3) 1 (11.1) 2 (3.4) 0.60 CKD, n (%) 26 (27.7) 3 (33.3) 34 (58.6) 0.001 EuroSCORE II ≥ 5, n (%) 20 (21.3) 5 (55.6) 30 (51.7) < 0.001 NYHA class, n (%) 0.19 2 20 (21.3) 2 (22.2) 7 (12.1) 3 42 (44.7) 3 (33.3) 20 (34.5) 4 32 (34.0) 4 (44.4) 31 (53.4) Severity of MR, n (%) 0.92 2+ 4 (4.3) 1 (11.1) 3 (5.2) 3+ 39 (41.5) 4 (44.4) 24 (41.4) 4+ 51 (54.3) 4 (44.4) 31 (53.4) EROA (mm 2 ), mean ± SD 40.40 ± 17.97 42.33 ± 7.02 36.05 ± 17.22 0.43 Barlow’s disease 49 (52.1) 0 (0.0) 0 (0.0) 1.00 Fibroelastic deficiency 20 (21.3) 0 (0.0) 0 (0.0) 1.00 MAC 44 (46.8) 3 (33.3) 12 (20.7) 0.005 MAD 19 (20.2) 3 (33.3) 3 (5.2) 0.014 LVEDDI (mm/m 2 ), mean ± SD 28.22 ± 4.6 24.61 ± 2.80 30.83 ± 5.46 0.003 LVESDI (mm/m 2 ), mean ± SD 18.98 ± 3.96 17.03 ± 3.56 24.29 ± 4.96 < 0.001 PASP (mmHg), mean ± SD 36.34 ± 11.61 32.33 ± 9.44 41.34 ± 10.24 0.04 LVEF (%), mean ± SD 53.61 ± 9.50 58.00 ± 5.74 44.06 ± 10.46 < 0.001 Mitral prosthetics (%) 0.003 Edwards Perimount Magna Ease 5 (5.3) 1 (11.1) 7 (12.1) Livanova Bicarbon 5 (5.3) 0 (0.0) 0 (0.0) Medtronic Mosaic 7 (7.4) 0 (0.0) 5 (8.6) On-X 0 (0.0) 1 (11.1) 0 (0.0) St Jude Epic 77 (81.9) 7 (77.8) 46 (79.3) Prostethic size (diameter), n (%) < 0.001 25 mm 0 (0.0) 1 (11.1) 0 (0.0) 27 mm 8 (8.5) 3 (33.3) 5 (8.6) 29 mm 30 (31.9) 3 (33.3) 20 (34.5) 31 mm 18 (19.1) 0 (0.0) 21 (36.2) 33 mm 38 (40.4) 2 (22.2) 12 (20.7) Associated CABG, n (%) 14 (14.9) 0 (0.0) 23 (39.7) < 0.001 CPBT (min), mean ± SD 80.10 ± 26.79 93.62 ± 36.77 90.44 ± 22.26 0.05 XCT (min), mean ± SD 57.00 ± 23.12 62.50 ± 18.91 61.48 ± 17.21 0.42 Abbreviations: AMI, acute myocardial infarction; CABG, coronary artery bypass grafting; CAD, coronary artery disease; CKD, chronic kidney disease; COPD, chronic obstructive pulmonary disease; CPBT, cardiopulmonary bypass time; EROA, effective regurgitant orifice area; LVEDDI, left ventricular end dyastolic diameter indexed; LVEF, left ventricular ejection fraction; LVESDI, left ventricular end systolic diameter indexed; MAC, mitral annular calcification; MAD, mitral annular disjunction; MR, mitral regurgitation; MV, mitral valve; NYHA, New York Heart Association; PMK, pacemaker; PASP, pulmonary artery systolic pressure; XCT, aortic cross-clamping time; BMI; IQR. The majority of subjects (66.5%) underwent concomitant surgical interventions, including 37 coronary artery bypass graft (CABG) procedures, 64 tricuspid valve repair operations, 11 aortic valve replacements, and 2 septal myectomies. Furthermore, 59 subjects exhibited mitral valve calcification, while 25 subjects demonstrated MAD ( Table 1 ). Notably, the vast majority of subjects (96.3%) were administered biological prostheses, whereas a comparatively smaller proportion (only 3.7%) were fitted with mechanical valves for mitral valve replacement. Within 12 months of FCR-MVRpl, 2 patients (1.2%) had procedure-related complications and were reoperated on for valve thrombosis. At the 12-month post-operative evaluation, freedom from post-operative complications of the FCR-MVRpl procedure was 98.6 ± 0.97% (Fig. 4). The study was completed at the 12 month follow-up period. Postoperative mortalities were observed in 14 patients within 30 days (8.7%) and 23 patients within 12 months (14.3%). The survival rate following FCR-MVRpl was 85.5% at 12 months post-surgery, with a standard deviation of ± 2.8% (Fig. 5). 12 months following FCR-MVRpl, LVEDDI was recorded as 26.07 ± 4.11 mm/m2, LVESDI as 18.48 ± 4.59 mm/m2 and LVEF as 49.93 ± 11.31%. A comparison of the baseline values revealed that LVEDDI and LVESDI had undergone significant improvement following a one-year period of observation (p < 0.001 and p < 0.001, respectively). No statistically significant differences were observed in LVEF over the same time period (p = 0.09). Excluding patients who did not reach 12 months of follow-up, 11 (8.0%) patients had a worse NYHA functional class compared to the start of the observation period. However, the majority of patients exhibited benefits from FCR-MVRpl, with 112 patients (81.2%) being in NYHA Class 1 (Fig. 6). Mitral prosthesis dysfunction was observed in a total of 2 patients (representing 1.2% of the study population) who subsequently developed thrombosis. At one year, 9 patients (5.6%) required re-hospitalisation for heart failure. The 1-year freedom from re-hospitalisation for heart failure was 94.2% ± 1.9%. The proportion of patients for whom treatment failed over 12 months is illustrated in Fig. 7. Multivariable Cox analysis revealed a trend towards higher risk of treatment failure in patients who had a preoperative lower rate of LVEF (hazard ratio: 0.95; 95% CI: 0.92 to 0.99; p = 0.015 by the log-rank test) ( Table 2 ). Within a period of one year, treatment failure was observed in 26 patients (16.1%) out of a total of 161 patients. Of these, 20 patients underwent additional procedures in conjunction with FCR-MVRpl, as detailed below: 7 cases of CABG, 2 cases of ascending aorta replacement, 1 case of aortic valve replacement, and 10 cases of tricuspid valve repair. The percentage of patients who were free from treatment failure at one year was 83.7 ± 2.9%, as illustrated in Fig. 7. Table 2 Multivariable Cox analysis results for the association with treatment failure Characteristics HR 95% CI p -value Age 1.03 0.99, 1.08 0.15 Female gender 0.80 0.34, 1.85 0.6 Diabetes 0.53 0.20, 1.39 0.2 LVEF 0.95 0.92, 0.99 0.015 MR grade 0.97 0.50, 1.87 > 0.9 Abbreviations: CI, confidence interval; HR, hazard ratio; LVEF, left ventricular ejection fraction; MR, mitral regurgitation. 5. Discussion The prevalence of mitral valve repair has increased in comparison to replacement procedures [ 15 , 16 ]. However, there is a lack of conclusive evidence from randomized trials that compares the relative merits of valvular and subvalvular repair in patients with severe functional mitral regurgitation [ 17 – 20 ] or bivalvular prolapse [ 20 , 21 ]. This evidence is particularly absent in cases of degenerative valve disease complicated by severe mitral annular calcification [ 20 , 21 ] or mitral annular disjunction [ 21 ]. The primary safety endpoint of the present trial is to identify procedure-related complications, which are characterised by heart injury and rupture, undersizing of the mitral prosthesis, absence of interference from the implanted prosthetic valve due to retained structure, absence of LVOT obstruction, and SVD/NSVD. The presence of these complications is often indicative of a poor prognosis for patients undergoing MVR procedures that involve the partial or complete preservation of the subvalvular apparatus [ 14 , 21 – 25 ]. The study found that, 12 months after surgery, the percentage of cases in which freedom from procedure-related complications was attained was 98.6 ± 0.97%, indicating an extremely high level of success for the FCR-MVRpl procedure. The findings of the present study, which was conducted over a period of 9 years, suggest that the FCR-MVRpl is beneficial in cases of both organic and functional mitral valve disorders. The technique under discussion offers distinct advantages in circumstances where the integrity of the mitral annular-papillary muscle continuity must be maintained during mitral valve replacement. This assertion carries particular pertinence in instances wherein the pathology of the mitral valve precludes the feasibility of a reparative intervention. This is particularly salient when degenerative disease has been accompanied by substantial calcification of the mitral annulus. This approach precludes the potential complications associated with other surgical methods [ 14 , 21 – 25 ], thereby enhancing its safety profile. The most significant concern associated with surgical interventions on the mitral valve pertains to the possibility of heart injury and rupture, largely attributed to the application of extreme annular traction and aggressive decalcification procedures [ 22 , 23 ]. This heightened risk is particularly pronounced in instances where there is an association between MAC and the occurrence of MAD [ 21 ]. It is imperative to exercise caution and avoid excessive decalcification of the mitral annulus during MV resection, a strategy that is especially salient in the context of geriatric patients to avert the potential for posterior ventricular rupture [ 22 ]. The investigation revealed that substantial mitral annulus calcification was not independently associated with complications related to the procedure. In this study, the FCR-MVRpl procedure was performed on 36.6% of patients with cumbersome and extensive mitral annular calcification. Moreover, no statistically significant discrepancy in postoperative mortality was observed between patients with and without extensive calcification undergoing the procedure. The extent of preservation of the anterior subvalvular apparatus was determined predominantly by a comprehensive surgical evaluation of the anterior mitral annulus extension of the pathoanatomic lesion. Consequently, the FCR-MVRpl was performed exclusively among patients devoid of substantial calcifications of the anterior annulus, owing to the potential risk of inducing trigonous damage. In cases where extensive calcifications have been observed along the entire leaflet implantation on the anterior annulus, and where decalcification has been found to involve excessive traction manipulation on the anterior trigone, a methodology has been devised that entails the sparing of only the posterior leaflet, inclusive of its subvalvular apparatus. The decision to perform a more extensive procedure on the entire subvalvular apparatus was driven by several factors. Firstly, the potential for removing calcifications that did not fully encircle the annulus, along with the adjacent cardiac muscle, or for those located in the posterior commissure, which could be more readily eliminated, was taken into consideration. Secondly, it was recognized that the selection of a more comprehensive procedure should be made by the surgeon, guided by their discretion regarding the patient’s preoperative condition and the degree of involvement of the anterior annulus. To mitigate this risk, preserving the physiological integrity of the intact subvalvular apparatus through the tethering effect is paramount [ 22 – 24 ], a strategy that not only prevents this complication but also exerts a beneficial influence on ventricular mechanics [ 12 , 13 , 26 , 27 ]. The study’s findings unequivocally demonstrate that the dimensions of the prosthesis align with the body surface area, thereby eradicating the potential for underestimation of the conventional stented xenograft bioprosthesis or mechanical valve size due to the presence of retained tissue. The valve size did not measure less than 29 millimeters, which corresponded to the most commonly implanted size (32.9%). Sizes 33 (32.3%) and 31 (24.2%) followed, respectively. In the present series, no instances of SVD were observed at the 12-month time point, which was designated as the primary endpoint of the study. However, in the event that a FCR-MVRpl is performed, it is imperative to consider the presence of additional clinical valve abnormalities that do not stem from deterioration of the valve tissue. These include patient-prosthesis mismatch, device malposition, and paravalvular regurgitation. It is noteworthy that these factors may be associated with early SVD, although they are not formally included in the definition of SVD. Of particular note is the challenge in distinguishing patient prosthesis mismatch from SVD, particularly in cases where leaflet morphology is deemed normal despite the relatively small valve area and elevated gradient. Moreover, in cases of patient-prosthesis mismatch, the aberrant valve hemodynamics are already present at the time of prosthesis implantation. In contrast to SVD and associated acquired stenosis, there is no deterioration in hemodynamics (increase in gradients and decrease in valve area) during follow-up [ 28 ]. The technique described herein involves addressing the anterior leaflet tissue in order to prevent malposition of the device, as well as paravalvular regurgitation and LVOT occlusion. CCS-MVR was performed in 58.4% of cases within the study group. Our study demonstrated that there was no impact on the altered dynamics of LVOT obstruction or impairment of mechanical or bioprosthetic valve function due to entrapment in the MVR with chordal sparring. This latter complication is a possible eventuality when the tissue exuberance is not properly removed during the anterior leaflet mobilisation procedure and its subsequent translocation [ 14 , 25 ]. In the present series, the only two instances of re-operation that were observed were due to thrombosis of the bioprosthesis in patients who had become arrhythmic due to atrial fibrillation and who were not receiving anticoagulant medication. The radiofrequency ablation of atrial fibrillation and ligation of the left atrial appendage were not recommended for these patients, as they did not align with the prevailing guidelines. Despite the anticipated greater technical complexity of Barlow disease surgery, particularly when associated with MAD or MAC, other studies have documented analogous levels of technical complexity [ 6 , 9 , 14 , 16 , 21 , 22 , 25 ]. Reports from other groups have demonstrated that the placement of a bioprosthesis following the removal of the anterior leaflet from the aortic curtain, subsequently utilised to reinforce the posterior sutures by transposing the anterior chordal attachments to the posterior annulus, has been associated with worse outcomes. This approach, involving the transposition of the anterior chordal attachments to the posterior annulus, has been shown to result in potential compromise to the bioprosthetic function of the valve due to entrapment in chordal-sparing mitral valve replacement [ 25 ]. In the study conducted by Prabhakar et al. [ 26 ], severe prosthetic mitral regurgitation was observed 2 months after chordal-sparing MV surgery. The posterior strut of the bioprosthesis was found to be embedded within the confines of the posterior papillary muscle. This phenomenon resulted in the obstruction of the cusps, thus hindering their proper apposition due to their separation. Additionally, a study reported dynamic LVOT obstruction in a patient where the anterior leaflet was retained during MVR, highlighting the potential risks associated with this approach [ 14 ]. In this particular case, the primary concern pertains to the systolic anterior movement of the native anterior leaflet. It is theorised that the reduced outflow tract diameter, a consequence of both posterior displacement of the septum and anterior displacement of the native anterior leaflet by stented xenograft bioprosthesis, played a pivotal role in the promotion of dynamic obstruction [ 14 ]. However, the discrepancy in surgical outcome [ 6 – 9 , 22 – 25 ] may be attributable to variations in surgical approach, with some surgeons opting for a procedure limited to posterior leaflet preservation, specifically in cases of Barlow’s disease complicated by MAD and/or MAC. In contrast, other surgeons may choose to perform a more extensive preservation in low-risk and/or younger patients with more suitable valve morphology. Furthermore, there is no consensus on which features should be considered when taking into account the extent of the MV disease (e.g., partial or massive annular calcifications or the size or extent of the anterior leaflet portion to be removed), and this may also contribute to the reported differences in practices and outcomes. The decision to select LVEDDI as the secondary endpoint was informed by substantial evidence that correlated LVEDDI with clinical outcomes, encompassing the NYHA classification, as well as rates of admission to hospital and survival [ 29 – 33 ]. In the present study, the surgical approach involving FCR-MVRpl resulted in a reduction of both LVEDD and LVESD at the 12-month time point. However, a statistical differential analysis comparing the degenerative and functional cohorts was not conducted. Subsequent to the adjustment of baseline confounders, LVEF was found to be independently associated with a higher risk of rehospitalisation for heart failure and treatment failure as a composite endpoint at 1 year following FCR-MVRpl. The reasons for the suboptimal outcomes observed in patients who were readmitted (5.6%) and those who experienced treatment failure (5.8%) following FCR-MVRpl remain uncertain and are unlikely to be fully attributable to variations in LV remodelling assessed by changes in indexed left ventricular end-systolic volume (LVESVI) and indexed left ventricular end-diastolic volume (LVEDVI) or differential responses to FCR-MVRpl in degenerative and functional cohorts. Further elucidation is necessary to clarify these observations. Patients suffering from degenerative disease have been shown to exhibit smaller ventricles and no altered spatial configuration of the mitral valve in comparison to patients with functional MV disease [ 16 , 18 , 19 , 29 , 34 – 38 ]. In the latter, changes in LVESVI over time have been shown to be strongly associated with worse outcomes in patients with residual scar tissue formation after myocardial infarction and lower LVEF [ 18 , 19 , 34 – 38 ]. Consequently, the deterioration of ventricular function can significantly limit the benefits offered by edge-to-edge transcatheter replacement procedures [ 39 ]. Conversely, conservative MVR procedures have been demonstrated to maintain the integrity of the subvalvular apparatus [ 5 , 6 , 8 , 9 , 40 ]. While LVESVI and LVEDVI demonstrated improvements over a 1-year period [ 18 , 34 ], disparities in the percentage of LVESVI changes between degenerative and functional diseases may exert an influence on left ventricular end systolic stress and function [ 6 , 16 , 26 , 27 ]. The discordant alterations that can be discerned in LVESVI are attributable to the interdependence among Left ventricular end-systolic stress (LVESS), LVESVI, LVEF, and LVEDVI post-MVR, as demonstrated in the mathematical model established by Goldfine et al. [ 26 ]. This model demonstrates that, for any given LVEDVI, a diminished LVEF is associated with an augmented LVESVI, which, consequently, results in an elevated LVESS by virtue of the Laplace relation. Secondly, it is conceivable that the higher severity Euroscore, older age and associated procedures may have influenced the re-hospitalisation rate and treatment failure [ 40 , 41 ]. 6. Limitation It is imperative to address the limitations of this study. The study is retrospective and observational in nature, which necessitates the adjustment for baseline differences in non-randomised studies. However, it should be noted that even with the application of these methods, there remains the possibility of unadjusted differences in cases where specific risk factors are either unknown or not measured. This may provide a rationale for the observed absence of significant differences in the rates of LVEDDI and LVESDI improvement, and enhanced short- or long-term LVEF in patients with degenerative or functional mitral disease, as reported in several studies [ 4 , 6 ]. Despite the thoroughness of the follow-up process, echocardiographic data were only documented at the 12-month mark during the final follow-up. This was in relation to a specific surgical endpoint. Furthermore, a certain degree of survivor bias cannot be ruled out [ 41 ]. Consequently, further research is required to ascertain the definitive effectiveness or limitations of this technique. Such research should utilise echocardiography, together with longitudinal analysis and computational modelling with finite element analysis. 7. Conclusion In conclusion, preservation of the mitral subvalvular apparatus during MVR has been shown to be safe and effective in terms of procedure-related complications, providing an early benefit by reducing LV chamber size and diastolic afterload. Therefore, in order to optimise early postoperative and late LV systolic function, when MVR is necessary, we recommend preserving all chordal structures by translocating the AML instead of quadripartitioning the MV. Despite the absence of robust scientific evidence, the field of surgery has adopted a reparative approach to the surgical management of the mitral valve, superseding the conventional replacement approach. According to data from the Society of Thoracic Surgeons, spanning the years 2008 to 2012, 66% of mitral valve surgeries performed on patients undergoing coronary artery bypass graft utilised a reparative approach [39]. However, in the context of patients afflicted with functional mitral regurgitation and severe mitral valve prolapse of both leaflets (Barlow’s disease), a re-evaluation of this approach may be warranted. These patients are typically considered unsuitable candidates for surgical mitral valve repair. The replacement of the mitral valve using the FCR-MVRpl procedure provides a significantly more durable correction of mitral regurgitation. It can be posited that the present situation may exert a considerable effect on long-term outcomes; however, this should be balanced against the deleterious effects associated with the utilisation of a prosthetic valve. Nevertheless, transcatheter mitral valve therapy has the potential to mitigate this issue. Abbreviations AML, anterior mitral leaflet; FCR-MVRpl, full chordal-rescue mitral valve replacement; LVEF, left ventricular ejection fraction; LVEDDI, left ventricular end dyastolic diameter indexed; LVEF, left ventricular ejection fraction; LVESDI, left ventricular end systolic diameter indexed; MAD, mitral annular disjunction; MAC, mitral annular calcification; MR, mitral regurgitation; MV, mitral valve; MVR, mitral valve replacement; NYHA, New York Heart Association; NSVD, nonstructural valve deterioration; SVD, structural valve deterioration. Declarations Acknowledgements Not applicable Author Contributions FN and IA designed the research study. FN, IA, SSAS and AA performed the substantial contributions to the analysis. CB, TS and NB provided the substantial interpretation of data for the work. FN wrote the manuscript. All authors contributed to editorial changes in the manuscript. All authors read and approved the final manuscript. All authors have participated sufficiently in the work and agreed to be accountable for all aspects of the work. All authors agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. Funding This study will be performed without external financial support. Data availability The provision of data will be considered on a case-by-case basis following consultation with the corresponding author. The data were utilised under a licensing agreement for the present study (IRB No. UM 2023-010), with restrictions that preclude their redistribution or public dissemination without prior consent from the IRB. Ethics Approval and Consent to Participate The authors are accountable for all aspects of the work, including ensuring the accuracy and integrity of each part. Any questions related to these aspects must be appropriately investigated and resolved. The Institutional Review Board (IRB) of the University of Montpellier ( [email protected] ) has formally approved the utilisation of the aforementioned data for research purposes. The principles established in the Declaration of Helsinki were followed, in addition to written informed consent having been provided by the patients in question. This approval is documented in the IRB's decision letter, bearing the reference number UM 2023-010 and dated May 17, 2023. Consent for publication This manuscript does not contain individual person’s data in any form. Competing interests The authors declare no competing interests. References David TE, Uden DE, Strauss HD. The importance of the mitral apparatus in left ventricular function after correction of mitral regurgitation. Circulation. 1983; 68: II76–82. Hennein HA, Swain JA, McIntosh CL, Bonow RO, Stone CD, Clark RE. Comparative assessment of chordal preservation versus chordal resection during mitral valve replacement. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6738874","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":487111906,"identity":"5a65b658-3b23-4e67-ba13-6cf7a46f1599","order_by":0,"name":"Francesco Nappi","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABA0lEQVRIiWNgGAWjYBAC9gYUroGNHIg68ACPFp4DqFrSjMFaEojXwnA4EWwtXi3Sh589+PHHRp5fuvnZ44IC5vT5YYcfAm2xk9NtwKGFL83csLctzXDmnGPmxjMM2HI33k4zAGpJNjY7gF2LPQ+DmTRjw+EEgxsJZtI8Bjy5G2cngLQcSNyGQwsPD/s3aYY//4Fa0r8BtUikG85O/0BAC4+ZNAPbAaCWHJAtBgny0jmEbOEpk+xtSzacOSOnHOiXBMMN0jkFQBNw+wXosG0SP/7YyfNLpG97XPDnv7z87PTNHz5U2Mnh0oIM2JhBpAFYpQFh5Qgt8g3EqR4Fo2AUjIKRAwBSCVoNQgN+SgAAAABJRU5ErkJggg==","orcid":"","institution":"Centre Cardiologique du Nord","correspondingAuthor":true,"prefix":"","firstName":"Francesco","middleName":"","lastName":"Nappi","suffix":""},{"id":487111908,"identity":"d39fe212-0d6f-47c3-b96a-05d8170c6b2b","order_by":1,"name":"Ibrahim Abdou","email":"","orcid":"","institution":"Centre Cardiologique du Nord","correspondingAuthor":false,"prefix":"","firstName":"Ibrahim","middleName":"","lastName":"Abdou","suffix":""},{"id":487111911,"identity":"fa8dcbd4-1d11-4783-a8f7-8f29418205c9","order_by":2,"name":"Antonio Salsano","email":"","orcid":"","institution":"University of Genoa","correspondingAuthor":false,"prefix":"","firstName":"Antonio","middleName":"","lastName":"Salsano","suffix":""},{"id":487111914,"identity":"a0e2153f-0913-4444-9ec8-f4d0858082b3","order_by":3,"name":"Ivancarmine Gambardella","email":"","orcid":"","institution":"Weill Cornell Medicine-New York, Presbyterian Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Ivancarmine","middleName":"","lastName":"Gambardella","suffix":""},{"id":487111918,"identity":"84bba879-fd50-4416-9f1f-da7515373a29","order_by":4,"name":"Sanjeet Singh Avtaar Singh","email":"","orcid":"","institution":"Royal Infirmary of Edinburgh","correspondingAuthor":false,"prefix":"","firstName":"Sanjeet","middleName":"Singh Avtaar","lastName":"Singh","suffix":""},{"id":487111921,"identity":"11cd798f-d900-4631-819a-f4c175a391dc","order_by":5,"name":"Almothana Alzamil","email":"","orcid":"","institution":"Centre Cardiologique du Nord","correspondingAuthor":false,"prefix":"","firstName":"Almothana","middleName":"","lastName":"Alzamil","suffix":""},{"id":487111924,"identity":"074e421e-ccf9-49e2-ba11-ecc420964bdd","order_by":6,"name":"Camille Bourgois","email":"","orcid":"","institution":"Centre Cardiologique du Nord","correspondingAuthor":false,"prefix":"","firstName":"Camille","middleName":"","lastName":"Bourgois","suffix":""},{"id":487111928,"identity":"44e138f7-e07a-40a3-ada1-326d77573157","order_by":7,"name":"Thibaut Schoell","email":"","orcid":"","institution":"Centre Cardiologique du Nord","correspondingAuthor":false,"prefix":"","firstName":"Thibaut","middleName":"","lastName":"Schoell","suffix":""},{"id":487111931,"identity":"d54037ea-3c95-4487-957f-75831e9875d8","order_by":8,"name":"Nicolas Bonnet","email":"","orcid":"","institution":"Centre Cardiologique du Nord","correspondingAuthor":false,"prefix":"","firstName":"Nicolas","middleName":"","lastName":"Bonnet","suffix":""}],"badges":[],"createdAt":"2025-05-24 11:53:19","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6738874/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6738874/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s13019-025-03831-x","type":"published","date":"2026-03-02T15:59:00+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":87321361,"identity":"badb7134-7cb2-4e4b-b417-2e887fc289b4","added_by":"auto","created_at":"2025-07-22 16:37:38","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":1193664,"visible":true,"origin":"","legend":"\u003cp\u003eThe illustration depicts the FCR-MVRpl. (A, B) The AML with a preserved chordal apparatus (illustrated with a yellow arrow) is incised across the entire anterior annulus from the posterior commissure (PC) to the anterior commissure (AC). Subsequently, the AML is repositioned and reattached to the posterior leaflet and annulus at the appropriate location (C). The stented bioprosthesis is then inserted (D). (E) The subvalvular apparatus is entirely retained without the presence of redundant tissue in the LV chamber. In cases of leaflet tissue redundancy resulting from Barlow disease, the surgical excision of an ellipse-shaped portion of the tissue along the length of the free edge leaflets at the A2 level and the level of the junction between A2/A1 and A2/A3 is imperative (Fig. 2A). This methodical approach ensures the excision of a 5- to 10-millimeter leaflet-free edge with only 3/4 basal chordae tendineae (Fig. 2A, B), while preserving the structural integrity of the left ventricle’s anatomical composition. FCR-MVRpl, full chordal rescue mitral valve replacement ; PML, posterior mitral leaflet; AML, anterior mitral leaflet; LV, left ventricular.\u003c/p\u003e","description":"","filename":"Fig1.png","url":"https://assets-eu.researchsquare.com/files/rs-6738874/v1/38b749eedc9d2305342cffea.png"},{"id":87319363,"identity":"fbf31538-ef1d-4dff-8cf6-7af42597cce0","added_by":"auto","created_at":"2025-07-22 16:21:38","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":578554,"visible":true,"origin":"","legend":"\u003cp\u003eThe biomechanical and morphological characteristics of the mitral valve and subvalvular apparatus are delineated. (A, B) In instances of tissue excess, as observed in Barlow disease, excision of a portion in the form of an ellipse may be indicated (red area), corresponding to A2 scallops and junction area A1/A2 and A2/A3 scallops with related basal chords, respectively. (B) The color illustration delineates the residual logarithmic strains in the collagen direction at the onset of systole, prior to ventricular pressure application on the leaflets.\u003c/p\u003e","description":"","filename":"Fig2.png","url":"https://assets-eu.researchsquare.com/files/rs-6738874/v1/4c1ce44c3c9d03aef952e735.png"},{"id":87319353,"identity":"d8d4feb5-8ebd-4606-b3e6-7095f1772ac8","added_by":"auto","created_at":"2025-07-22 16:21:38","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":705120,"visible":true,"origin":"","legend":"\u003cp\u003eThe flowchart. Abbreviations: CCF, chronic cardiac failure; FCR-MVRpl, full chordal-rescue mitral valve replacement ; MV, mitral valve ; PCR-MVRpl, partial chordal rescue mitral valve replacement, AML, Anterior Mitral Leaflet.\u003c/p\u003e","description":"","filename":"Fig3.png","url":"https://assets-eu.researchsquare.com/files/rs-6738874/v1/f6f20da786664ded9f4fb3f2.png"},{"id":87320532,"identity":"4fc81355-0b4f-4cd7-953a-5c4dddb36346","added_by":"auto","created_at":"2025-07-22 16:29:38","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":711051,"visible":true,"origin":"","legend":"\u003cp\u003eKaplan–Meier curves for freedom from procedural-related complications after FCR-MVRpl at 1 year.\u003c/p\u003e","description":"","filename":"Figure4.png","url":"https://assets-eu.researchsquare.com/files/rs-6738874/v1/b41f9706319a7cafa5aa86c2.png"},{"id":87319360,"identity":"72ee27a3-2c49-49e6-8e7b-0299fb736f99","added_by":"auto","created_at":"2025-07-22 16:21:38","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":556738,"visible":true,"origin":"","legend":"\u003cp\u003eKaplan–Meier curves for freedom from death after FCR-MVRpl at 1 year.\u003c/p\u003e","description":"","filename":"Figure5.png","url":"https://assets-eu.researchsquare.com/files/rs-6738874/v1/30002f25462f034672ab57e6.png"},{"id":87319356,"identity":"69ac16bf-12bd-41e5-bc5c-3553ed3e2310","added_by":"auto","created_at":"2025-07-22 16:21:38","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":1661528,"visible":true,"origin":"","legend":"\u003cp\u003eNew York Heart Association (NYHA) functional class modifications. Changes are depicted according to the aetiology of mitral regurgitation at baseline and 1 year after FCR-MVRpl.\u003c/p\u003e","description":"","filename":"Fig6.png","url":"https://assets-eu.researchsquare.com/files/rs-6738874/v1/3687e68ed8795ac7806444f0.png"},{"id":87320535,"identity":"d9897f62-cca8-4fc2-81bd-c6e99d62d491","added_by":"auto","created_at":"2025-07-22 16:29:38","extension":"png","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":562992,"visible":true,"origin":"","legend":"\u003cp\u003eKaplan–Meier curves for freedom from treatment failure after FCR-MVRpl at 1 year.\u003c/p\u003e","description":"","filename":"Figure7.png","url":"https://assets-eu.researchsquare.com/files/rs-6738874/v1/ec50a99b213f44525bbcaa3e.png"},{"id":104250831,"identity":"84295a70-1463-42ec-b5a4-c68833761e9f","added_by":"auto","created_at":"2026-03-09 16:09:31","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":6915335,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6738874/v1/0e5cd509-23c0-424c-85c2-893a44bbfa39.pdf"},{"id":87320531,"identity":"484a2893-3b3a-48f3-b53e-43b2593b3c78","added_by":"auto","created_at":"2025-07-22 16:29:38","extension":"csv","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":3593,"visible":true,"origin":"","legend":"","description":"","filename":"Survival.csv","url":"https://assets-eu.researchsquare.com/files/rs-6738874/v1/77bdef379f6d4dbd37e2992c.csv"}],"financialInterests":"No competing interests reported.","formattedTitle":"A report on the successful rescue of the entire anterior mitral leaflet through the implementation of a bespoke procedure in the context of mitral valve replacement","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eIt has been demonstrated in both experimental and clinical studies that it is of significant importance to maintain the integrity of the subvalvular apparatus during the process of mitral valve replacement (MVR) [\u003cspan additionalcitationids=\"CR2 CR3\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. This was accomplished through an examination of the influence exerted on ventricular functionality as a consequence of partial [\u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] or total [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] surgical sparring of the mitral valve apparatus. Additionally, the utilization of Gore-Tex sutures (W. L. Gore, Flagstaff, AZ) was employed with the objective of guaranteeing uninterrupted continuity between the mitral annulus and the papillary muscles (PMs) [\u003cspan additionalcitationids=\"CR8\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe following report delineates the methodology we have devised to maintain the subvalvular apparatus of the mitral valve (MV) in a manner that is both physiological and anatomical. The surgical technique under consideration involves the transection of the entire anterior mitral leaflet (AML), thereby facilitating a comprehensive full chordal rescue mitral valve replacement (FCR-MVRpl) (\u003cb\u003eFig.\u0026nbsp;1A\u0026ndash;E)\u003c/b\u003e. This procedure is predicated on three fundamental tenets. Firstly, a sufficient amount of surrounding tissue must be removed in order to facilitate the successful implantation of an adequately sized valve. Secondly, it is essential that no interference occurs with the functionality of the prosthetic valve due to the preserved structure. Thirdly, it is imperative to avoid the formation of any obstruction within the left ventricular outflow tract.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cp\u003e The study was granted ethical approval by the institutional review board of University of Montpellier (IRB reference number No. UM 2023-010, May 17) and the requirement for individual patient consent was waived. A retrospective review was conducted on a prospectively maintained database of patients who underwent surgical treatment for MV disease between 2014 and 2023. This repository of data is subject to continuous updates and maintenance by clinical information experts. The data collection process is subjected to regular validation through both internal and external control mechanisms. Variables pertaining to the preoperative and postoperative periods are entered prospectively during the course of the patient\u0026rsquo;s hospitalization, while follow-up data are entered at subsequent encounters. Updates to follow-up data pertaining to survival and reintervention were conducted through a review of the electronic medical record, communication with referring medical practitioners, or direct engagement with patients and their families. Prior to the commencement of statistical analysis, the French national mortality database (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.insee.fr\u003c/span\u003e\u003cspan address=\"https://www.insee.fr\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e) was consulted in order to ascertain the most recent data available at the time of the data freeze.\u003c/p\u003e\u003cp\u003eThe primary safety endpoint was defined as the absence of procedural-related complications within 12 months. A procedural-related complication was defined as follows: any occurrence necessitating undersizing of the mitral prosthetic, resulting in patient-prosthesis mismatch; absence of the interference of the implanted prosthetic valve by the preserved valvular and subvalvular structure; absence of left ventricular outflow tract (LVOT) obstruction; structural/nonstructural valve deterioration (SVD/NSVD); and cardiac rupture. SVD was defined according to the recent consensus statement from the European Association of Percutaneous Cardiovascular Interventions. The aforementioned statement posits a distinction between hemodynamic and morphological SVD [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eSecondary endpoints encompassed death, the mean percentage change in left ventricular end-diastolic dimensions index (LVEDDI), a worsened New York Heart Association (NYHA) class or rehospitalisation for heart failure within 12 months, in addition to mitral prosthesis dysfunction, including prosthesis regurgitation grade and thrombosis requiring reoperation. Furthermore, treatment failure was identified as a composite endpoint (CEP) at 12 months, characterised by the occurrence of death, mitral valve reoperation, or recurrence of moderate or severe mitral prosthesis dysfunction.\u003c/p\u003e\u003cp\u003eA sternotomy was performed on all patients. The procedure employs standard bicaval cannulation, whereby exposure of the valve is achieved via a transatrial incision, as previously described by Guiraudon et al. [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. A standard normothermic (36 ℃) cardiopulmonary bypass was employed for the purpose of myocardial protection. The cardioplegia used was either antegrade intermittent warm potassium-rich or both antegrade and retrograde warm potassium-rich. The latter was used in patients requiring procedures associated with prolonged cardiopulmonary bypass. For patients who require systemic cooling, warming was achieved by maintaining a 10 ℃ temperature difference between core blood and internal temperature during surgical hemostasis. Cardiopulmonary bypass was stopped once the body temperature reached 36 ℃.\u003c/p\u003e\u003cp\u003eIn instances where the valve was deemed irreparable following preoperative echocardiography and in situ exploration of the MV lesion, the AML was detached from the annulus between the two commissures \u003cb\u003e(Fig.\u0026nbsp;1A,B).\u003c/b\u003e Upon full mobilisation, the AML was accompanied by its complete subvalvular apparatus, which consisted of between four and six equally distributed chords for each papillary muscle \u003cb\u003e(Fig.\u0026nbsp;2B).\u003c/b\u003e\u003c/p\u003e\u003cp\u003eIn the treatment of patients diagnosed with Barlow\u0026rsquo;s disease and bivalvular prolapse, the excision of 3\u0026ndash;5 mm of excess tissue \u003cb\u003e(Fig.\u0026nbsp;2B)\u003c/b\u003e may significantly reduce the risk of excessive neocollagenisation of the bioprosthesis stent, with the potential for involvement of the leaflets and subsequent development of secondary stenosis. Furthermore, the removal of excess valvular tissue is an effective procedure to mitigate the risk of LVOT obstruction \u003cb\u003e(Fig.\u0026nbsp;2A,B).\u003c/b\u003e The subsequent step involves the reattachment of the AML to the posterior leaflet and annulus, which occurs in the corresponding location with the prothesis valve sutures, as illustrated in Fig.\u0026nbsp;1C. It is noteworthy that the normal geometry is likely to be maintained with greater efficacy in cases wherein the anterior leaflet has not been subdivided [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. The utilization of FCR-MVRpl is contraindicated in instances of substantial thickening or calcification in either the AML or the annulus, necessitating the implementation of alternative measures. The procedure of elliptic excision of tissue will not be carried out if, upon examination, the AML is found to be relatively uncompromised, as previously described by Sintek and colleagues [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Consequently, the leaflet tissue with the primary chordae must not be reattached to the anterior annulus using mattress sutures, which are subsequently employed for prosthetic valve implantation. The entire mitral annulus is to be in contact with the mitral prostheses \u003cb\u003e(Fig.\u0026nbsp;1D,E).\u003c/b\u003e\u003c/p\u003e\u003cp\u003eIn certain instances, the redundant and excessive tissue cannot be excised and is instead employed for the repair of the mitral annular disjunction (MAD), when it occurs in conjunction with degenerative mitral valve disease, or sutured on the atrial side of the annulus in patients with mitral annular calcification (MAC), prior to the tying of prosthetic valve sutures. A 4\u0026thinsp;\u0026minus;\u0026thinsp;0 Prolene suture (Ethicon, Sommerville, NJ, USA) is used for two purposes in the attachment of markedly redundant tissue to the left atrial endocardium. First, it serves to reinforce the posterior mitral annulus. Second, it is employed to prevent the redundant tissue from AML from extending over the sewing ring.\u003c/p\u003e\u003cp\u003eThe complete mobilisation of the AML and its insertion into the posterior annulus and prosthetic valve (Fig.\u0026nbsp;1C\u0026ndash;E) will prevent any protrusion into the LVOT or interference with prosthetic valve function (Fig.\u0026nbsp;1D,E). The double valve procedure (aortic and mitral) has afforded the chance to visually inspect the left ventricular chamber via the open aorta, enabling observation of retained AML structures within the LVOT. Obstruction is effectively avoided through AML translocation, although issues can arise when excessive AML tissue is retained post-partition three and four on the mitral annulus\u0026rsquo;s aortic aspect [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe PML, when sufficiently pliable, can typically be maintained in situ with the attached chordae. Excessive redundancy in the leaflet tissue is folded into the annulus and advanced to the leading edge of the leaflet tissue. Conversely, in the event of extensive redundancy, thickening, and fibrosis of the PML, a small wedge resection is performed to facilitate the implantation of a larger prosthetic.\u003c/p\u003e\u003cp\u003eIn cases where patients present with infective endocarditis (IE) involving multiple infected leaflets and poor annular consistency, surgical repair is not recommended. Therefore, the recommended surgical approach is concomitant mitral valve replacement, utilising a conventional stented xenograft or mechanical prosthesis. In such cases, the translocated tissue of the AML can be employed in the repair of abscess formation on the posterior annulus. In cases necessitating comprehensive repair of the posterior mitral annulus due to IE, the entire AML with its chordal apparatus is employed for annular reconstruction. It is recommended that mitral valve annulus reconstruction be performed prior to the insertion of prostheses, using the AML, which should be sutured with 4\u0026thinsp;\u0026minus;\u0026thinsp;0 polypropylene.\u003c/p\u003e\u003cp\u003eThe relocation of the rescued AML can result in the formation of a properly neoannulus, which serves to prevent the dangerous decalcification of the native annulus in patients presenting with massive posterior MAC, with or without MAD. In the event that the leaflet tissue is of sufficient consistency, the AML can be sutured over the PML. Alternatively, sutures can be passed from the left atrium around the retracted mitral annulus directly over the AML, encasing the prosthetic valve stent. This technique serves to reduce the potential for traction between the calcific annulus, PML, and subvalvular apparatus, thereby avoiding the strain that would otherwise be placed on fragile structures. Patients with diffuse myxomatous degeneration have been observed to exhibit an abnormal systolic superior shift of the papillary muscles, accompanied by traction. Although there is likely a relationship between abnormal papillary muscle mechanical motion and MAD, further investigations are required to determine the optimal surgical approach to avoid deleterious complications.\u003c/p\u003e"},{"header":"3. Statistical Analysis","content":"\u003cp\u003eCategorical data are presented as frequencies and percentages in text and tables, with Fisher\u0026rsquo;s exact test or the chi-square test used as appropriate. The normality criteria were met for each continuous variable. For normally distributed data, independent sample or paired sample t-tests were employed, with mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation or median and interquartile range presented in text and tables.\u003c/p\u003e\u003cp\u003eThe development of event-free survival curves was facilitated through the implementation of the Kaplan\u0026ndash;Meier method. In order to account for the presumed correlation with treatment failure, a multivariable model was performed, incorporating baseline age, gender, diabetes, left ventricular ejection fraction (LVEF), and severity of mitral regurgitation (MR).\u003c/p\u003e\u003cp\u003eTreatment effects were estimated as hazard ratios with 95% confidence intervals. Derivation of these intervals utilised the Cox proportional hazards model, whilst the proportional hazards assumption was assessed via a graphical method. A p value less than 0.05 was designated as statistically significant. The analyses were conducted utilising R statistical software, version 4.3.1 (R Foundation for Statistical Computing, Vienna, Austria).\u003c/p\u003e"},{"header":"4. Results","content":"\u003cp\u003eThe present study was conducted between January 2014 and November 2023, and its primary objective was to investigate the outcomes of FCR-MVRpl using the AML translocation, with a particular focus on the incidence of adverse events. Indications for FCR-MVRpl included degenerative valve disease in 58.4% of cases (94 patients), functional MR in 36.0% (58 patients), and infective endocarditis in 5.6% (9 patients). The mean age of subjects undergoing FCR-MVRpl was recorded as 72.52 years, with a standard deviation of \u0026plusmn;\u0026thinsp;10.36 years. The most common underlying cause of functional mitral regurgitation was secondary ischemic MR in 72.4% of cases. Furthermore, it is notable that MAD occurred in 15.5% of patients, and 36.6% presented with severe mitral valve calcification.\u003c/p\u003e\n\u003cp\u003eThe baseline characteristics of the entire patient population are delineated in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e. As illustrated in \u003cstrong\u003eFig.\u0026nbsp;3\u003c/strong\u003e, the flow chart is presented.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab1\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eBaseline characteristics of the overall patient population (n\u0026thinsp;=\u0026thinsp;161).\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eClinical characteristics\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eDegenerative MR (n\u0026thinsp;=\u0026thinsp;94)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eEndocarditis (n\u0026thinsp;=\u0026thinsp;9)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eFunctional MR (n\u0026thinsp;=\u0026thinsp;58)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e\u003cem\u003ep\u003c/em\u003e value\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eAge (years),\u0026nbsp;(median [IQR])\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e74.00 [69.00, 80.00]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e73.00 [61.00, 82.00]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e71.50 [67.00, 78.00]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.35\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eFemale, n (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e45 (47.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5 (55.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e22 (37.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.39\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eBMI, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e26.29\u0026thinsp;\u0026plusmn;\u0026thinsp;5.42\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e24.66 \u0026plusmn; 3.29\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e25.58\u0026thinsp;\u0026plusmn;\u0026thinsp;4.99\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.54\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eBSA, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.83\u0026thinsp;\u0026plusmn;\u0026thinsp;0.22\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.79\u0026thinsp;\u0026plusmn;\u0026thinsp;0.14\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.81\u0026thinsp;\u0026plusmn;\u0026thinsp;0.23\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.85\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eHypertension, n (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e53 (56.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5 (55.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e34 (58.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.96\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eSmoke, n (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e27 (28.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3 (33.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e23 (39.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.38\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eDiabetes, n (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e16 (17.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3 (33.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e27 (46.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eHypercholesterolemia, n (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e29 (30.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4 (44.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e35 (60.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.002\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eCAD, n (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e17 (18.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2 (22.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e40 (69.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eAMI, n (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2 (2.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1 (11.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e33 (56.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003ePrevious cardiac surgery, n (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6 (6.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3 (33.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e12 (20.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.007\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003ePrevious CABG, n (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0 (0.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1 (11.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4 (6.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.02\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003ePeripheral vascular disease, n (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e10 (10.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0 (0.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4 (6.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.46\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eCOPD, n (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6 (6.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0 (0.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3 (5.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.72\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eAtrial fibrillation, n (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e40 (42.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2 (22.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e31 (53.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.15\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eDefinitive PMK, n (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3 (3.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1 (11.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e7 (12.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.19\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eStroke, n (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5 (5.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1 (11.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2 (3.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.60\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eCKD, n (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e26 (27.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3 (33.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e34 (58.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eEuroSCORE II\u0026thinsp;\u0026ge;\u0026thinsp;5, n (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e20 (21.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5 (55.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e30 (51.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eNYHA class, n (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.19\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e20 (21.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2 (22.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e7 (12.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e42 (44.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3 (33.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e20 (34.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e32 (34.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4 (44.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e31 (53.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eSeverity of MR, n (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.92\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2+\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4 (4.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1 (11.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3 (5.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3+\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e39 (41.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4 (44.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e24 (41.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4+\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e51 (54.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4 (44.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e31 (53.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eEROA (mm\u003csup\u003e2\u003c/sup\u003e), mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e40.40\u0026thinsp;\u0026plusmn;\u0026thinsp;17.97\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e42.33\u0026thinsp;\u0026plusmn;\u0026thinsp;7.02\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e36.05\u0026thinsp;\u0026plusmn;\u0026thinsp;17.22\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.43\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eBarlow\u0026rsquo;s disease\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e49 (52.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0 (0.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0 (0.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.00\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eFibroelastic deficiency\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e20 (21.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0 (0.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0 (0.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.00\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eMAC\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e44 (46.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3 (33.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e12 (20.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.005\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eMAD\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e19 (20.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3 (33.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3 (5.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.014\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eLVEDDI (mm/m\u003csup\u003e2\u003c/sup\u003e), mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e28.22\u0026thinsp;\u0026plusmn;\u0026thinsp;4.6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e24.61\u0026thinsp;\u0026plusmn;\u0026thinsp;2.80\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e30.83\u0026thinsp;\u0026plusmn;\u0026thinsp;5.46\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.003\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eLVESDI (mm/m\u003csup\u003e2\u003c/sup\u003e), mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e18.98\u0026thinsp;\u0026plusmn;\u0026thinsp;3.96\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e17.03\u0026thinsp;\u0026plusmn;\u0026thinsp;3.56\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e24.29\u0026thinsp;\u0026plusmn;\u0026thinsp;4.96\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003ePASP (mmHg), mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e36.34\u0026thinsp;\u0026plusmn;\u0026thinsp;11.61\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e32.33\u0026thinsp;\u0026plusmn;\u0026thinsp;9.44\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e41.34\u0026thinsp;\u0026plusmn;\u0026thinsp;10.24\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.04\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eLVEF (%), mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e53.61\u0026thinsp;\u0026plusmn;\u0026thinsp;9.50\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e58.00\u0026thinsp;\u0026plusmn;\u0026thinsp;5.74\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e44.06\u0026thinsp;\u0026plusmn;\u0026thinsp;10.46\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eMitral prosthetics (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.003\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eEdwards Perimount Magna Ease\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5 (5.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1 (11.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e7 (12.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eLivanova Bicarbon\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5 (5.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0 (0.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0 (0.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMedtronic Mosaic\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e7 (7.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0 (0.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5 (8.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eOn-X\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0 (0.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1 (11.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0 (0.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSt Jude Epic\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e77 (81.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e7 (77.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e46 (79.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eProstethic size (diameter), n (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e25 mm\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0 (0.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1 (11.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0 (0.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e27 mm\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e8 (8.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3 (33.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5 (8.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e29 mm\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e30 (31.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3 (33.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e20 (34.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e31 mm\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e18 (19.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0 (0.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e21 (36.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e33 mm\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e38 (40.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2 (22.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e12 (20.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eAssociated CABG, n (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e14 (14.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0 (0.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e23 (39.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eCPBT (min), mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e80.10\u0026thinsp;\u0026plusmn;\u0026thinsp;26.79\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e93.62\u0026thinsp;\u0026plusmn;\u0026thinsp;36.77\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e90.44\u0026thinsp;\u0026plusmn;\u0026thinsp;22.26\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.05\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eXCT (min), mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e57.00\u0026thinsp;\u0026plusmn;\u0026thinsp;23.12\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e62.50\u0026thinsp;\u0026plusmn;\u0026thinsp;18.91\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e61.48\u0026thinsp;\u0026plusmn;\u0026thinsp;17.21\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.42\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eAbbreviations: AMI, acute myocardial infarction; CABG, coronary artery bypass grafting; CAD, coronary artery disease; CKD, chronic kidney disease; COPD, chronic obstructive pulmonary disease; CPBT, cardiopulmonary bypass time; EROA, effective regurgitant orifice area; LVEDDI, left ventricular end dyastolic diameter indexed; LVEF, left ventricular ejection fraction; LVESDI, left ventricular end systolic diameter indexed;\u0026nbsp; MAC, mitral annular calcification; MAD, mitral annular disjunction; MR, mitral regurgitation; MV, mitral valve; NYHA, New York Heart Association; PMK, pacemaker; PASP, pulmonary artery systolic pressure; XCT, aortic cross-clamping time; BMI; IQR.\u003c/p\u003e\n\u003cp\u003eThe majority of subjects (66.5%) underwent concomitant surgical interventions, including 37 coronary artery bypass graft (CABG) procedures, 64 tricuspid valve repair operations, 11 aortic valve replacements, and 2 septal myectomies. Furthermore, 59 subjects exhibited mitral valve calcification, while 25 subjects demonstrated MAD \u003cstrong\u003e(\u003c/strong\u003eTable\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e\u003cstrong\u003e).\u003c/strong\u003e Notably, the vast majority of subjects (96.3%) were administered biological prostheses, whereas a comparatively smaller proportion (only 3.7%) were fitted with mechanical valves for mitral valve replacement.\u003c/p\u003e\n\u003cp\u003eWithin 12 months of FCR-MVRpl, 2 patients (1.2%) had procedure-related complications and were reoperated on for valve thrombosis. At the 12-month post-operative evaluation, freedom from post-operative complications of the FCR-MVRpl procedure was 98.6\u0026thinsp;\u0026plusmn;\u0026thinsp;0.97% \u003cstrong\u003e(Fig.\u0026nbsp;4).\u003c/strong\u003e The study was completed at the 12 month follow-up period. Postoperative mortalities were observed in 14 patients within 30 days (8.7%) and 23 patients within 12 months (14.3%). The survival rate following FCR-MVRpl was 85.5% at 12 months post-surgery, with a standard deviation of \u0026plusmn;\u0026thinsp;2.8% \u003cstrong\u003e(Fig.\u0026nbsp;5).\u003c/strong\u003e 12 months following FCR-MVRpl, LVEDDI was recorded as 26.07\u0026thinsp;\u0026plusmn;\u0026thinsp;4.11 mm/m2, LVESDI as 18.48\u0026thinsp;\u0026plusmn;\u0026thinsp;4.59 mm/m2 and LVEF as 49.93\u0026thinsp;\u0026plusmn;\u0026thinsp;11.31%. A comparison of the baseline values revealed that LVEDDI and LVESDI had undergone significant improvement following a one-year period of observation (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001 and p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, respectively). No statistically significant differences were observed in LVEF over the same time period (p\u0026thinsp;=\u0026thinsp;0.09). Excluding patients who did not reach 12 months of follow-up, 11 (8.0%) patients had a worse NYHA functional class compared to the start of the observation period. However, the majority of patients exhibited benefits from FCR-MVRpl, with 112 patients (81.2%) being in NYHA Class 1 \u003cstrong\u003e(Fig.\u0026nbsp;6).\u003c/strong\u003e Mitral prosthesis dysfunction was observed in a total of 2 patients (representing 1.2% of the study population) who subsequently developed thrombosis.\u003c/p\u003e\n\u003cp\u003eAt one year, 9 patients (5.6%) required re-hospitalisation for heart failure. The 1-year freedom from re-hospitalisation for heart failure was 94.2% \u0026plusmn; 1.9%. The proportion of patients for whom treatment failed over 12 months is illustrated in \u003cstrong\u003eFig.\u0026nbsp;7.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMultivariable Cox analysis revealed a trend towards higher risk of treatment failure in patients who had a preoperative lower rate of LVEF (hazard ratio: 0.95; 95% CI: 0.92 to 0.99; p\u0026thinsp;=\u0026thinsp;0.015 by the log-rank test) \u003cstrong\u003e(\u003c/strong\u003eTable\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e\u003cstrong\u003e).\u003c/strong\u003e Within a period of one year, treatment failure was observed in 26 patients (16.1%) out of a total of 161 patients. Of these, 20 patients underwent additional procedures in conjunction with FCR-MVRpl, as detailed below: 7 cases of CABG, 2 cases of ascending aorta replacement, 1 case of aortic valve replacement, and 10 cases of tricuspid valve repair. The percentage of patients who were free from treatment failure at one year was 83.7\u0026thinsp;\u0026plusmn;\u0026thinsp;2.9%, as illustrated in \u003cstrong\u003eFig.\u0026nbsp;7.\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab2\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eMultivariable Cox analysis results for the association with treatment failure\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eCharacteristics\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eHR\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e95% CI\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e\u003cem\u003ep\u003c/em\u003e-value\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAge\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.03\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.99, 1.08\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.15\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eFemale gender\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.80\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.34, 1.85\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.6\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDiabetes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.53\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.20, 1.39\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.2\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eLVEF\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.95\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.92, 0.99\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.015\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMR grade\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.97\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.50, 1.87\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026gt;\u0026thinsp;0.9\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAbbreviations: CI, confidence interval; HR, hazard ratio; LVEF, left ventricular ejection fraction; MR, mitral regurgitation.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"5. Discussion","content":"\u003cp\u003eThe prevalence of mitral valve repair has increased in comparison to replacement procedures [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. However, there is a lack of conclusive evidence from randomized trials that compares the relative merits of valvular and subvalvular repair in patients with severe functional mitral regurgitation [\u003cspan additionalcitationids=\"CR18 CR19\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] or bivalvular prolapse [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. This evidence is particularly absent in cases of degenerative valve disease complicated by severe mitral annular calcification [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] or mitral annular disjunction [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe primary safety endpoint of the present trial is to identify procedure-related complications, which are characterised by heart injury and rupture, undersizing of the mitral prosthesis, absence of interference from the implanted prosthetic valve due to retained structure, absence of LVOT obstruction, and SVD/NSVD. The presence of these complications is often indicative of a poor prognosis for patients undergoing MVR procedures that involve the partial or complete preservation of the subvalvular apparatus [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan additionalcitationids=\"CR22 CR23 CR24\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. The study found that, 12 months after surgery, the percentage of cases in which freedom from procedure-related complications was attained was 98.6\u0026thinsp;\u0026plusmn;\u0026thinsp;0.97%, indicating an extremely high level of success for the FCR-MVRpl procedure.\u003c/p\u003e\u003cp\u003eThe findings of the present study, which was conducted over a period of 9 years, suggest that the FCR-MVRpl is beneficial in cases of both organic and functional mitral valve disorders. The technique under discussion offers distinct advantages in circumstances where the integrity of the mitral annular-papillary muscle continuity must be maintained during mitral valve replacement. This assertion carries particular pertinence in instances wherein the pathology of the mitral valve precludes the feasibility of a reparative intervention. This is particularly salient when degenerative disease has been accompanied by substantial calcification of the mitral annulus. This approach precludes the potential complications associated with other surgical methods [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan additionalcitationids=\"CR22 CR23 CR24\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e], thereby enhancing its safety profile.\u003c/p\u003e\u003cp\u003eThe most significant concern associated with surgical interventions on the mitral valve pertains to the possibility of heart injury and rupture, largely attributed to the application of extreme annular traction and aggressive decalcification procedures [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. This heightened risk is particularly pronounced in instances where there is an association between MAC and the occurrence of MAD [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. It is imperative to exercise caution and avoid excessive decalcification of the mitral annulus during MV resection, a strategy that is especially salient in the context of geriatric patients to avert the potential for posterior ventricular rupture [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe investigation revealed that substantial mitral annulus calcification was not independently associated with complications related to the procedure. In this study, the FCR-MVRpl procedure was performed on 36.6% of patients with cumbersome and extensive mitral annular calcification. Moreover, no statistically significant discrepancy in postoperative mortality was observed between patients with and without extensive calcification undergoing the procedure. The extent of preservation of the anterior subvalvular apparatus was determined predominantly by a comprehensive surgical evaluation of the anterior mitral annulus extension of the pathoanatomic lesion. Consequently, the FCR-MVRpl was performed exclusively among patients devoid of substantial calcifications of the anterior annulus, owing to the potential risk of inducing trigonous damage.\u003c/p\u003e\u003cp\u003eIn cases where extensive calcifications have been observed along the entire leaflet implantation on the anterior annulus, and where decalcification has been found to involve excessive traction manipulation on the anterior trigone, a methodology has been devised that entails the sparing of only the posterior leaflet, inclusive of its subvalvular apparatus. The decision to perform a more extensive procedure on the entire subvalvular apparatus was driven by several factors. Firstly, the potential for removing calcifications that did not fully encircle the annulus, along with the adjacent cardiac muscle, or for those located in the posterior commissure, which could be more readily eliminated, was taken into consideration. Secondly, it was recognized that the selection of a more comprehensive procedure should be made by the surgeon, guided by their discretion regarding the patient\u0026rsquo;s preoperative condition and the degree of involvement of the anterior annulus. To mitigate this risk, preserving the physiological integrity of the intact subvalvular apparatus through the tethering effect is paramount [\u003cspan additionalcitationids=\"CR23\" citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e], a strategy that not only prevents this complication but also exerts a beneficial influence on ventricular mechanics [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe study\u0026rsquo;s findings unequivocally demonstrate that the dimensions of the prosthesis align with the body surface area, thereby eradicating the potential for underestimation of the conventional stented xenograft bioprosthesis or mechanical valve size due to the presence of retained tissue. The valve size did not measure less than 29 millimeters, which corresponded to the most commonly implanted size (32.9%). Sizes 33 (32.3%) and 31 (24.2%) followed, respectively.\u003c/p\u003e\u003cp\u003eIn the present series, no instances of SVD were observed at the 12-month time point, which was designated as the primary endpoint of the study. However, in the event that a FCR-MVRpl is performed, it is imperative to consider the presence of additional clinical valve abnormalities that do not stem from deterioration of the valve tissue. These include patient-prosthesis mismatch, device malposition, and paravalvular regurgitation. It is noteworthy that these factors may be associated with early SVD, although they are not formally included in the definition of SVD. Of particular note is the challenge in distinguishing patient prosthesis mismatch from SVD, particularly in cases where leaflet morphology is deemed normal despite the relatively small valve area and elevated gradient. Moreover, in cases of patient-prosthesis mismatch, the aberrant valve hemodynamics are already present at the time of prosthesis implantation. In contrast to SVD and associated acquired stenosis, there is no deterioration in hemodynamics (increase in gradients and decrease in valve area) during follow-up [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe technique described herein involves addressing the anterior leaflet tissue in order to prevent malposition of the device, as well as paravalvular regurgitation and LVOT occlusion. CCS-MVR was performed in 58.4% of cases within the study group. Our study demonstrated that there was no impact on the altered dynamics of LVOT obstruction or impairment of mechanical or bioprosthetic valve function due to entrapment in the MVR with chordal sparring. This latter complication is a possible eventuality when the tissue exuberance is not properly removed during the anterior leaflet mobilisation procedure and its subsequent translocation [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. In the present series, the only two instances of re-operation that were observed were due to thrombosis of the bioprosthesis in patients who had become arrhythmic due to atrial fibrillation and who were not receiving anticoagulant medication. The radiofrequency ablation of atrial fibrillation and ligation of the left atrial appendage were not recommended for these patients, as they did not align with the prevailing guidelines.\u003c/p\u003e\u003cp\u003eDespite the anticipated greater technical complexity of Barlow disease surgery, particularly when associated with MAD or MAC, other studies have documented analogous levels of technical complexity [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Reports from other groups have demonstrated that the placement of a bioprosthesis following the removal of the anterior leaflet from the aortic curtain, subsequently utilised to reinforce the posterior sutures by transposing the anterior chordal attachments to the posterior annulus, has been associated with worse outcomes. This approach, involving the transposition of the anterior chordal attachments to the posterior annulus, has been shown to result in potential compromise to the bioprosthetic function of the valve due to entrapment in chordal-sparing mitral valve replacement [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. In the study conducted by Prabhakar et al. [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e], severe prosthetic mitral regurgitation was observed 2 months after chordal-sparing MV surgery. The posterior strut of the bioprosthesis was found to be embedded within the confines of the posterior papillary muscle. This phenomenon resulted in the obstruction of the cusps, thus hindering their proper apposition due to their separation. Additionally, a study reported dynamic LVOT obstruction in a patient where the anterior leaflet was retained during MVR, highlighting the potential risks associated with this approach [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. In this particular case, the primary concern pertains to the systolic anterior movement of the native anterior leaflet. It is theorised that the reduced outflow tract diameter, a consequence of both posterior displacement of the septum and anterior displacement of the native anterior leaflet by stented xenograft bioprosthesis, played a pivotal role in the promotion of dynamic obstruction [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eHowever, the discrepancy in surgical outcome [\u003cspan additionalcitationids=\"CR7 CR8\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan additionalcitationids=\"CR23 CR24\" citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] may be attributable to variations in surgical approach, with some surgeons opting for a procedure limited to posterior leaflet preservation, specifically in cases of Barlow\u0026rsquo;s disease complicated by MAD and/or MAC. In contrast, other surgeons may choose to perform a more extensive preservation in low-risk and/or younger patients with more suitable valve morphology. Furthermore, there is no consensus on which features should be considered when taking into account the extent of the MV disease (e.g., partial or massive annular calcifications or the size or extent of the anterior leaflet portion to be removed), and this may also contribute to the reported differences in practices and outcomes.\u003c/p\u003e\u003cp\u003eThe decision to select LVEDDI as the secondary endpoint was informed by substantial evidence that correlated LVEDDI with clinical outcomes, encompassing the NYHA classification, as well as rates of admission to hospital and survival [\u003cspan additionalcitationids=\"CR30 CR31 CR32\" citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. In the present study, the surgical approach involving FCR-MVRpl resulted in a reduction of both LVEDD and LVESD at the 12-month time point. However, a statistical differential analysis comparing the degenerative and functional cohorts was not conducted. Subsequent to the adjustment of baseline confounders, LVEF was found to be independently associated with a higher risk of rehospitalisation for heart failure and treatment failure as a composite endpoint at 1 year following FCR-MVRpl. The reasons for the suboptimal outcomes observed in patients who were readmitted (5.6%) and those who experienced treatment failure (5.8%) following FCR-MVRpl remain uncertain and are unlikely to be fully attributable to variations in LV remodelling assessed by changes in indexed left ventricular end-systolic volume (LVESVI) and indexed left ventricular end-diastolic volume (LVEDVI) or differential responses to FCR-MVRpl in degenerative and functional cohorts. Further elucidation is necessary to clarify these observations.\u003c/p\u003e\u003cp\u003ePatients suffering from degenerative disease have been shown to exhibit smaller ventricles and no altered spatial configuration of the mitral valve in comparison to patients with functional MV disease [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan additionalcitationids=\"CR35 CR36 CR37\" citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. In the latter, changes in LVESVI over time have been shown to be strongly associated with worse outcomes in patients with residual scar tissue formation after myocardial infarction and lower LVEF [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan additionalcitationids=\"CR35 CR36 CR37\" citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. Consequently, the deterioration of ventricular function can significantly limit the benefits offered by edge-to-edge transcatheter replacement procedures [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. Conversely, conservative MVR procedures have been demonstrated to maintain the integrity of the subvalvular apparatus [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. While LVESVI and LVEDVI demonstrated improvements over a 1-year period [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e], disparities in the percentage of LVESVI changes between degenerative and functional diseases may exert an influence on left ventricular end systolic stress and function [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. The discordant alterations that can be discerned in LVESVI are attributable to the interdependence among Left ventricular end-systolic stress (LVESS), LVESVI, LVEF, and LVEDVI post-MVR, as demonstrated in the mathematical model established by Goldfine et al. [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. This model demonstrates that, for any given LVEDVI, a diminished LVEF is associated with an augmented LVESVI, which, consequently, results in an elevated LVESS by virtue of the Laplace relation. Secondly, it is conceivable that the higher severity Euroscore, older age and associated procedures may have influenced the re-hospitalisation rate and treatment failure [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e].\u003c/p\u003e"},{"header":"6. Limitation","content":"\u003cp\u003eIt is imperative to address the limitations of this study. The study is retrospective and observational in nature, which necessitates the adjustment for baseline differences in non-randomised studies. However, it should be noted that even with the application of these methods, there remains the possibility of unadjusted differences in cases where specific risk factors are either unknown or not measured. This may provide a rationale for the observed absence of significant differences in the rates of LVEDDI and LVESDI improvement, and enhanced short- or long-term LVEF in patients with degenerative or functional mitral disease, as reported in several studies [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Despite the thoroughness of the follow-up process, echocardiographic data were only documented at the 12-month mark during the final follow-up. This was in relation to a specific surgical endpoint. Furthermore, a certain degree of survivor bias cannot be ruled out [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. Consequently, further research is required to ascertain the definitive effectiveness or limitations of this technique. Such research should utilise echocardiography, together with longitudinal analysis and computational modelling with finite element analysis.\u003c/p\u003e"},{"header":"7. Conclusion","content":"\u003cp\u003eIn conclusion, preservation of the mitral subvalvular apparatus during MVR has been shown to be safe and effective in terms of procedure-related complications, providing an early benefit by reducing LV chamber size and diastolic afterload. Therefore, in order to optimise early postoperative and late LV systolic function, when MVR is necessary, we recommend preserving all chordal structures by translocating the AML instead of quadripartitioning the MV. Despite the absence of robust scientific evidence, the field of surgery has adopted a reparative approach to the surgical management of the mitral valve, superseding the conventional replacement approach. According to data from the Society of Thoracic Surgeons, spanning the years 2008 to 2012, 66% of mitral valve surgeries performed on patients undergoing coronary artery bypass graft utilised a reparative approach [39]. However, in the context of patients afflicted with functional mitral regurgitation and severe mitral valve prolapse of both leaflets (Barlow\u0026rsquo;s disease), a re-evaluation of this approach may be warranted. These patients are typically considered unsuitable candidates for surgical mitral valve repair. The replacement of the mitral valve using the FCR-MVRpl procedure provides a significantly more durable correction of mitral regurgitation. It can be posited that the present situation may exert a considerable effect on long-term outcomes; however, this should be balanced against the deleterious effects associated with the utilisation of a prosthetic valve. Nevertheless, transcatheter mitral valve therapy has the potential to mitigate this issue.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eAML, anterior mitral leaflet;\u003c/p\u003e\n\u003cp\u003eFCR-MVRpl, full chordal-rescue mitral valve replacement;\u003c/p\u003e\n\u003cp\u003eLVEF, left ventricular ejection fraction;\u003c/p\u003e\n\u003cp\u003eLVEDDI, left ventricular end dyastolic diameter indexed;\u003c/p\u003e\n\u003cp\u003eLVEF, left ventricular ejection fraction;\u003c/p\u003e\n\u003cp\u003eLVESDI, left ventricular end systolic diameter indexed;\u003c/p\u003e\n\u003cp\u003eMAD, mitral annular disjunction;\u003c/p\u003e\n\u003cp\u003eMAC, mitral annular calcification; MR, mitral regurgitation;\u003c/p\u003e\n\u003cp\u003eMV, mitral valve;\u003c/p\u003e\n\u003cp\u003eMVR, mitral valve replacement;\u003c/p\u003e\n\u003cp\u003eNYHA, New York Heart Association;\u003c/p\u003e\n\u003cp\u003eNSVD, nonstructural valve deterioration;\u003c/p\u003e\n\u003cp\u003eSVD, structural valve deterioration.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFN and IA designed the research study. FN, IA, SSAS and AA performed the substantial contributions to the analysis. CB, TS and NB provided the substantial interpretation of data for the work. FN wrote the manuscript. All authors contributed to editorial changes in the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003eAll authors have participated sufficiently in the work and agreed to be accountable for all aspects of the work. All authors agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study will be performed without external financial support.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe provision of data will be considered on a case-by-case basis following consultation with the corresponding author. The data were utilised under a licensing agreement for the present study (IRB No. UM 2023-010), with restrictions that preclude their redistribution or public dissemination without prior consent from the IRB.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics Approval and Consent to Participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors are accountable for all aspects of the work, including ensuring the accuracy and integrity of each part. Any questions related to these aspects must be appropriately investigated and resolved. The Institutional Review Board (IRB) of the University of Montpellier ([email protected]) has formally approved the utilisation of the aforementioned data for research purposes. The principles established in the Declaration of Helsinki were followed, in addition to written informed consent having been provided by the patients in question. This approval is documented in the IRB's decision letter, bearing the reference number UM 2023-010 and dated May 17, 2023.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis manuscript does not contain individual person\u0026rsquo;s data in any form.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eDavid TE, Uden DE, Strauss HD. The importance of the mitral apparatus in left ventricular function after correction of mitral regurgitation. Circulation. 1983; 68: II76\u0026ndash;82.\u003c/li\u003e\n\u003cli\u003eHennein HA, Swain JA, McIntosh CL, Bonow RO, Stone CD, Clark RE. Comparative assessment of chordal preservation versus chordal resection during mitral valve replacement. 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The New England Journal of Medicine. 2014; 370: 23\u0026ndash;32. https://doi.org/10.1056/NEJMoa1312808.\u003c/li\u003e\n\u003cli\u003eGoldstein D, Moskowitz AJ, Gelijns AC, Ailawadi G, Parides MK, Perrault LP, et al. Two-Year Outcomes of Surgical Treatment of Severe Ischemic Mitral Regurgitation. The New England Journal of Medicine. 2016; 374: 344\u0026ndash;353. https://doi.org/10.1056/NEJMoa1512913.\u003c/li\u003e\n\u003cli\u003eYun KL, Sintek CF, Miller DC, Schuyler GT, Fletcher AD, Pfeffer TA, et al. Randomized trial of partial versus complete chordal preservation methods of mitral valve replacement: A preliminary report. Circulation. 1999; 100: II90\u0026ndash;4. https://doi.org/10.1161/01.cir.100.suppl_2.ii-90.\u003c/li\u003e\n\u003cli\u003eEriksson MJ, Bitkover CY, Omran AS, David TE, Ivanov J, Ali MJ, et al. Mitral annular disjunction in advanced myxomatous mitral valve disease: echocardiographic detection and surgical correction. Journal of the American Society of Echocardiography: Official Publication of the American Society of Echocardiography. 2005; 18: 1014\u0026ndash;1022. https://doi.org/10.1016/j.echo.2005.06.013.\u003c/li\u003e\n\u003cli\u003eDeniz H, Sokullu O, Sanioglu S, Sargin M, Ozay B, Ayoglu U, et al. Risk factors for posterior ventricular rupture after mitral valve replacement: results of 2560 patients. European Journal of Cardio-thoracic Surgery: Official Journal of the European Association for Cardio-thoracic Surgery. 2008; 34: 780\u0026ndash;784. https://doi.org/10.1016/j.ejcts.2008.06.009.\u003c/li\u003e\n\u003cli\u003eSersar SI, Jamjoom AA. Left ventricular rupture post mitral valve replacement. Clinical Medicine. Cardiology. 2009; 3: 101\u0026ndash;113. https://doi.org/10.4137/cmc.s2533.\u003c/li\u003e\n\u003cli\u003eOkita Y, Miki S, Ueda Y, Tahata T, Sakai T, Matsuyama K. Mitral valve replacement with maintenance of mitral annulopapillary muscle continuity in patients with mitral stenosis. The Journal of Thoracic and Cardiovascular Surgery. 1994; 108: 42\u0026ndash;51.\u003c/li\u003e\n\u003cli\u003ePrabhakar G, Kumar N, Hatle L, al-Halees Z, Duran CM. Accelerated failure of bioprosthesis by entrapment in chordal-sparing mitral valve replacement. The Journal of Thoracic and Cardiovascular Surgery. 1994; 108: 185\u0026ndash;187.\u003c/li\u003e\n\u003cli\u003eGoldfine H, Aurigemma GP, Zile MR, Gaasch WH. Left ventricular length-force-shortening relations before and after surgical correction of chronic mitral regurgitation. Journal of the American College of Cardiology. 1998; 31: 180\u0026ndash;185. https://doi.org/10.1016/s0735-1097(97)00453-1.\u003c/li\u003e\n\u003cli\u003eHiemstra YL, Tomsic A, van Wijngaarden SE, Palmen M, Klautz RJM, Bax JJ, et al. 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European Journal of Heart Failure. 2009; 11: 480\u0026ndash;488. https://doi.org/10.1093/eurjhf/hfp034.\u003c/li\u003e\n\u003cli\u003eNappi F, Lusini M, Spadaccio C, Nenna A, Covino E, Acar C, et al. Papillary Muscle Approximation Versus Restrictive Annuloplasty Alone for Severe Ischemic Mitral Regurgitation. Journal of the American College of Cardiology. 2016; 67: 2334\u0026ndash;2346. https://doi.org/10.1016/j.jacc.2016.03.478.\u003c/li\u003e\n\u003cli\u003eNappi F, Spadaccio C, Nenna A, Lusini M, Fraldi M, Acar C, et al. Is subvalvular repair worthwhile in severe ischemic mitral regurgitation? Subanalysis of the Papillary Muscle Approximation trial. The Journal of Thoracic and Cardiovascular Surgery. 2017; 153: 286\u0026ndash;295.e2. https://doi.org/10.1016/j.jtcvs.2016.09.050.\u003c/li\u003e\n\u003cli\u003eNappi F, Lusini M, Avtaar Singh SS, Santana O, Chello M, Mihos CG. Risk of Ischemic Mitral Regurgitation Recurrence After Combined Valvular and Subvalvular Repair. The Annals of Thoracic Surgery. 2019; 108: 536\u0026ndash;543. https://doi.org/10.1016/j.athoracsur.2018.12.030.\u003c/li\u003e\n\u003cli\u003eNappi F, Avatar Singh SS, Santana O, Mihos CG. Functional mitral regurgitation: an overview for surgical management framework. Journal of Thoracic Disease. 2018; 10: 4540\u0026ndash;4555. https://doi.org/10.21037/jtd.2018.07.07.\u003c/li\u003e\n\u003cli\u003eNappi F, Singh SS. Subannular repair or transcatheter edge-to-edge repair for secondary mitral regurgitation? More data for international guidelines. JTCVS open. 2022; 10: 176\u0026ndash;180.\u003c/li\u003e\n\u003cli\u003eNappi F, Spadaccio C. The right horse for the race in the finite element analysis simulations to predict mitral valve regurgitation following transcatheter edge-to-edge mitral valve repair. European Heart Journal. Cardiovascular Imaging. 2025; jeaf068. https://doi.org/10.1093/ehjci/jeaf068.\u003c/li\u003e\n\u003cli\u003eNappi F, Salsano A, Abdou I, Gambardella I, Avtaar Singh SS, Alzamil A, et al. Translocated anterior mitral leaflet sparing is a viable treatment option for both degenerative and functional mitral valve disease. Journal of Thoracic Disease. 2025; 17: 707\u0026ndash;723. https://doi.org/10.21037/jtd-24-1555.\u003c/li\u003e\n\u003cli\u003eYears 2008-2012:the Adult Cardiac Surgery Database. Chicago: Society of Thoracic Surgeons (http://www.sts.org/national-database).\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-cardiothoracic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jcts","sideBox":"Learn more about [Journal of Cardiothoracic Surgery](http://cardiothoracicsurgery.biomedcentral.com)","snPcode":"13019","submissionUrl":"https://submission.nature.com/new-submission/13019/3","title":"Journal of Cardiothoracic Surgery","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"mitral valve (MV), mitral valve replacement (MVR), chordal preservation, chordal sparing","lastPublishedDoi":"10.21203/rs.3.rs-6738874/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6738874/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e A bespoke procedure for the replacement of the mitral valve (MV) was devised, with the aim of preserving the rescued anterior mitral leaflet (AML). The approach employed involved the implementation of a full chordal-rescue mitral valve replacement (FCR-MVRpl), with the objective of preserving the anatomical configuration of the left ventricle. This technique has been shown to be beneficial for patients suffering from various forms of MV disease, including functional, degenerative, and infectious MV disease, who were previously unable to undergo MV repair. The investigation aimed to determine whether the technique caused procedural complications and if so, whether these resulted in left ventricular (LV) remodelling and how it affected survival rates.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e The study population comprised 161 patients, of whom 94 (57.1%) had degenerative mitral valve disease, 58 (36.0%) had functional mitral valve disease, 9 (5.6%) had infective mitral valve disease, and 2 (1.2%) had rheumatic mitral valve disease. In the 93 patients diagnosed with complicated MV disease, massive calcification was observed in 59 cases (36.6%), while 25 (15.5%) cases demonstrated mitral annular disjunction (MAD) and 9 (5.6%) cases presented with endocarditis and posterior annular abscesses. The anterior leaflet was completely rescued and then dislocated from its attachment to the annulus, a condition spanning from the posterior commissure to the anterior commissure. In cases involving excess tissue, a segment of the free edge of the translocated leaflet had to be excised, ensuring the preservation of a small section of the edge and the entire chordae tendineae unit.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e Within 12 months following FCR-MVRpl, 2 patients (1.2%) experienced procedural-related complications. The freedom from procedural-related complications after FCR-MVRpl was 98.6 ± 0.97% at 12 months after surgery. The 1-year freedom from re-hospitalisation for heart failure was 94.2% ± 1.9%. Multivariable Cox analysis revealed a trend towards higher risk of treatment failure in patients who had a preoperative lower rate of LVEF (hazard ratio: 0.95; 95% CI: 0.92 to 0.99; \u003cem\u003ep\u003c/em\u003e = 0.015 by the log-rank test). With the exception of patients who did not reach 12 months of follow-up, 11 (8.0%) patients exhibited a deterioration in their New York Heart Association (NYHA) functional class. However, most patients showed clinical benefits following FCR-MVRpl. Indeed, 112 patients (81.2%) were classified into NYHA Class I.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eThe FCR-MVRpl is considered both safe and effective for a variety of cases without procedural-related complications. This technique preserves the left ventricle from dilatation and is beneficial for patients unable to undergo MV repair. The AML is used to treat severe cases of calcified posterior mitral annulus, complicated Barlow disease and endocarditis involving the posterior annulus. The FCR-MVRpl is not recommended for cases of severe complete MV calcification.\u003c/p\u003e","manuscriptTitle":"A report on the successful rescue of the entire anterior mitral leaflet through the implementation of a bespoke procedure in the context of mitral valve replacement","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-22 16:21:33","doi":"10.21203/rs.3.rs-6738874/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-09-28T02:31:35+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-27T04:07:44+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-26T13:44:46+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"9916139840731537566413028707106039289","date":"2025-07-19T04:54:46+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"67163136348445629786169527695193062608","date":"2025-07-17T22:25:16+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"76930294666312410740036675552867335992","date":"2025-07-15T16:08:29+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-07-15T13:55:24+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-05-26T10:22:50+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-05-26T10:18:44+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Cardiothoracic Surgery","date":"2025-05-24T11:41:57+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-cardiothoracic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jcts","sideBox":"Learn more about [Journal of Cardiothoracic Surgery](http://cardiothoracicsurgery.biomedcentral.com)","snPcode":"13019","submissionUrl":"https://submission.nature.com/new-submission/13019/3","title":"Journal of Cardiothoracic Surgery","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"bf4001cc-95f2-4ac7-9d27-2ef573d7d9f5","owner":[],"postedDate":"July 22nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-03-09T16:06:28+00:00","versionOfRecord":{"articleIdentity":"rs-6738874","link":"https://doi.org/10.1186/s13019-025-03831-x","journal":{"identity":"journal-of-cardiothoracic-surgery","isVorOnly":false,"title":"Journal of Cardiothoracic Surgery"},"publishedOn":"2026-03-02 15:59:00","publishedOnDateReadable":"March 2nd, 2026"},"versionCreatedAt":"2025-07-22 16:21:33","video":"","vorDoi":"10.1186/s13019-025-03831-x","vorDoiUrl":"https://doi.org/10.1186/s13019-025-03831-x","workflowStages":[]},"version":"v1","identity":"rs-6738874","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6738874","identity":"rs-6738874","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}