Conclusion
The aims of each and every MVr, whatever the technique used, must be to restore a coaptation height between A2 and P2 of 8 to 10 mm, to restore coaptation depth, to respect leaflet mobility and to achieve a harmonious 2/3 – 1/3 (even 3/4 – 1/4) closure line.
The concept of « respect without resection » sounds very appealing as it is easy and fast to perform. Therefore, it has gained further popularity, especially with minimally invasive MV surgery approach .
Our personal opinion is that the « respect » technique’s major drawback is related to the tension applied to the chordae as keeping all the pathological tissue necessarily increases the tension on them. In turn, this leads to early failures due to recurrent prolapse with or without chordal rupture or tear of the leaflet.
The coaptation height (which is measured in end systole in between A2 and P2) is never equal to the height of P2. This technique brings an asymmetrical coaptation with the tip of A2, and, therefore, a false sense of security given that one could believe that « the reserve of coaptation » of the new MV is very high.
Another issue with the concept of non-resection is the mandatory pulling of P2 downwards in the left ventricle, so that the indentations become wide open and require closure, as P2 is not at the same level as P1 and P3 anymore. As opposed to this technique the resection technique never open the indentations and their closure is not necessary .
Finally, the ultimate goal of all mitral repair strategies should be to decrease excess tension at each and every level of the mitral apparatus. We therefore believe that oversimplification applicable to all mitral repairs such as artificial chordae and ring annuloplasty is quite appealing but surely not realistic. Moreover, patients need to do well, early and later, in order to keep mitral repair as the gold standard [4]. Little is known about the long-term results of those advocating such simplification. Major recognized surgical teams in the world, showing results with a follow up of 10 years or more and with longitudinal echocardiographic data, use a variety of resection techniques as a key point in the treatment of most degenerative MV diseases (Cleveland Clinic, Mayo Clinic, Toronto General Hospital, Mount Sinai,…[8,9,10,11,12,13,14] ), as we also do.