Cardiovascular Surgery, Vol. 9, No. 1, pp.

58–63, 2001
 2001 The International Society for Cardiovascular Surgery. Published by Elsevier Science Ltd
All rights reserved. Printed in Great Britain
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PII: S0967-2109(00)00086-7

www.elsevier.com/locate/cardiosur

Is posterior leaflet preservation in the surgical

treatment of rheumatic mitral insufficiency
without left ventricular dysfunction necessary?†
Kaan Kırali, Altuǧ Tuncer, İbrahim Uyar, Denyan Mansuroǧlu, Bahadır Daǧlar,
Gökhan İpek, Ömer Işık and Cevat Yakut
Koşuyolu Heart and Research Hospital, Istanbul, Turkey

Preservation of the mitral valve leaflet and tensor apparatus during valve replacement is
believed to maintain left ventricular performance. To determine the effect of posterior leaflet
preservation in pure severe mitral insufficiency without left ventricular dysfunction 56 patients
were operated on between 1993 and 2000. Twenty-three patients underwent mitral valve
replacement with posterior chordal preservation and 33 patients underwent mitral valve
replacement with chordal transection. Preoperative data in the both groups were similar. After
30 days there were no mortalities observed. Dimensions of the left ventricle had significantly
decreased within one group, but there was no difference in the other group. The improvement
of the functional and cardiac performance in all patients was significant without any difference
between the two groups. Actuarial freedom from death was not significantly different at 6 yr
(P ⫽ 0.23). To preserve left ventricular function in pure severe mitral regurgitation without
left ventricular dysfunction, mitral valve replacement is very effective with or without posterior
leaflet preservation. But, it is difficult to suggest that posterior leaflet preservation alone can
increase cardiac performance.  2001 The International Society for Cardiovascular Surgery.
Published by Elsevier Science Ltd. All rights reserved

Keywords: posterior leaflet preservation, mitral regurgitation, mitral valve replacement

Introduction true beneficial effect of the preservation of the whole

In chronic mitral regurgitation, the myocardium
responds to the augmented filling volume by adding
sarcomeres in series and in parallel, thereby altering
ventricular geometry [1]. This adaptation facilitates
a markedly increased left ventricular filling volume
at physiological pressures and may contribute to the
prolonged asymtomatic period. In spite of this, it was
reported that the preservation of posterior leaflet and
its chordae decreased the incidence of low cardiac
output syndrome after mitral valve replacement. The
Correspondence to: K. Kırali, M.D., Koşuyolu Kalp Eǧitim ve
Araştırma Hastanesi, 81020, Kadıköy-İstanbul, Türkıye. Tel.: ⫹ 90-
216-325-5457; fax: ⫹ 90-216-339-0441; E-mail: kosuyolu@sup
eronline.com
†Presented at the 9th World Congress of Word Society of Cardio-
Thoracic Surgeons, 14–17 November 1999, Lisbon
annulo-papillary continuity on left ventricular func-
tion was observed in the last decade [2–9]. In
patients with chronic mitral regurgitation, standard
mitral valve replacement with transection of the
chordae tendineae usually results in a decrease in left
ventricular ejection performance [10]. The mitral
valve apparatus may make an important contribution
to global and regional left ventricular contractile
function. Most surgeons retain only the posterior
leaflet and excise the entire anterior leaflet so as to
prevent both interference with prosthetic valvular
function and obstruction of the left ventricular out-
flow tract [11, 12]. In spite of experimental studies
which have demonstrated that the anterior and pos-
terior leaflet chordae had similar but additive contri-
butions to contractile function [13], the effect of only
posterior leaflet preservation in chronic mitral insuf-
ficiency is disputatious [6, 14].

58 CARDIOVASCULAR SURGERY FEBRUARY 2001 VOL 9 NO 1

 Posterior leaflet preservation in rheumatic mitral insufficiency: Kaan Kırali et al.

The purpose of this study is to show whether pres-
ervation of the posterior leaflet had a beneficial effect
on left ventricular function in patients with severe
mitral insufficiency and unimpaired left ventricular
function.
Methods
Fifty-six symptomatic patients with isolated severe
mitral valve regurgitation (Sellers degree III or IV)
were treated with the mitral valve replacement with
(MVR–PCP) or without (MVR–CT) posterior
leaflet preservation between March 1993 and March
2000 (Table 1). Patients with associated cardiac dis-
eases (coronary artery disease, aortic valve disease),
infective endocarditis, previous mitral regurgitation
surgery or ischemic mitral regurgitation were not
admitted to the study. The patients were selected
randomly and the selected surgical technique was
applied without reference to the anatomic structure
or the thickness of the posterior leaflet. The anterior
leaflet was resected in all patients, because of the
severity of calcification or the thickness.
Calculations
Preoperative and postoperative left ventricular func-
tions were compared. Left atrial diameter (LAD),
left ventricular end systolic diameter (LVESD) and
left ventricular end diastolic diameter (LVEDD); left
ventricular endsystolic volume (LVESV) and end-
diastolic volume (LVEDV) and total stroke volume
(LVSV) and forward stroke volume (LVFSV) were
measured echocardiographically. Fractional shorten-
ing (FS) was calculated as ‘FS ⫽ {(LVEDD ⫺
LVESD)/LVEDD} ⫻ 100’. Global ejection fraction
(EF) was calculated as total stroke volume (LVSV)
divided by the difference between left ventricular end
diastolic (LVEDV) and systolic (LVESV) volumes.
Forward ejection fraction was calculated LVFSV
divided by the difference between LVEDV and
LVESV.
Statistical analysis
Values are given as mean ⫾ SD. Comparison of
means between preoperative and postoperative per-
iods were evaluated with paired t-test for differences
of parameters within the groups, and with unpaired
t-test and chi-square test for differences between
groups. The cumulative probability of survival was
estimated by the Kaplan–Meier method. Using log
rank test compared the survival curves. P ⬍ 0.05 was
considered significant.
Results
Follow-up accuracy was 100% for this study.
Mortality
Overall mortality was 1.78% (1/56), a patient in
Group A (mortality 4.34%). He was discharged

Table 1 Preoperative data of patients

MVR–PCP MVR–CT P

Age (yr) 33.8 ⫾ 18.4 31.5 ⫾ 15 0.49

Sex (female/male) 14/9 18/15 0.64
Etiology 0.82
Rheumatic 21 (91.4%) 30 (90.9%)
Degenerative 1 (4.3%) 3 (9.1%)
Congenital (MVP) 1 (4.3%) –
Associated cardiac pathology 0.83
Severe tricuspid insufficiency 3 (23.1%) 8 (24.2%)
Atrial septal defect 1 (7.7%) 1 (3%)
Associated procedures 0.49
DeVega annuloplasty 5 (21.7%) 6 (18.1%)
ASD closure 1 (4.3%) 1 (3%)
Pulmonary artery pressure 58.1 ⫾ 20 53.6 ⫾ 15 0.4
Range (mmHg) 35–100 35–80
Prosthetic valves
Mechanic 22 (95.7%) 33 (100%)
Bileaflet 16 21
Monoleaflet 6 12
Bioprostheses 1 (4.3%) –
Prosthetic valve size
25 2 6
27 9 9
29 10 12
31 1 4
33 1 2

CARDIOVASCULAR SURGERY FEBRUARY 2001 VOL 9 NO 1 59

Posterior leaflet preservation in rheumatic mitral insufficiency: Kaan Kırali et al.

from the hospital at the end of the first postoper-

ative week, but he came back after one week with
pericardial effusion. After revision, sepsis and low
cardiac output developed. He died on the 45th
postoperative day and the cause of death was septic
multiorgan failure. We did not observe any late
mortality. Actuarial freedom from death was not
significantly different at 6 yr (95.65 ⫾ 4.25% ver-
sus 100%; P ⫽ 0.23).
Morbidity
There were one revision for bleeding and one transi-
ent atrio-ventricular block in each group.
Postoperative valve-related complications
No patient died, and no case of valve related event,
i.e. valve thrombosis, embolism, anticoagulant
related bleeding, paravalvular leakage, endocarditis,
hemolysis or restriction of mitral valve motion was
observed during long-term follow-up period.
Pre- and postoperative arrhythmia
Preoperatively there was no statistically significant
difference in the prevalence of supraventricular
arrhythmia between groups. Sinus rhythm was
present in 14/23 (60.8%) in group A and 20/33
(60.6%) in group B (P ⫽ 0.95). Preservation of the
mitral posterior leaflet did not result in a significant
postoperative reduction of supraventricular arrhyth-
mia. Sinus rhythm was present in 16/23 (69.5%)
patients in group A and in 21/33 (63.6%) patients
in group B (P ⫽ 0.73). Figure 1 Functional capacity of both groups in preoperative (above) and
early postoperative period (below)
Pre- and postoperative functional capacity
There was no statistically significant difference in the
prevalence of functional capacity between groups in Echocardiographic examination two months after
the pre- and postoperative period. Functional MVR demonstrated no significantly changes on the
capacity was improved in all patients after mitral diameters and function of the left heart between
valve replacement (Figure 1). groups (Table 3).
Operative and postoperative period Noticeably, a marked decrease of the dimensions
caused by mitral valve replacement was observed in
Cross-clamp and total perfusion time were similar in each group, however, decrease of FS and EF was not
each group: 64.9 ⫾ 19.3 and 86.1 ⫾ 23.3 min in significant in the postoperative period (Table 4).
group A versus 60.8 ⫾ 22.4 and 81.4 ⫾ 19.8 min in
group B (P ⫽ 0.6).
The protection of the myocardium in the both Discussion
groups was similar. We used blood cardioplegia in Mitral regurgitation is a valvular disease that pro-
19 (82.6%) of patients in group A and in 29 (87.9%) duces complex hemodynamic alterations. In chronic
of patients in group B (P ⫽ 0.67). mitral insufficiency the left ventricle undergoes an
All patients were discharged from the hospital at initial dilation followed by the development of
the end of the first postoperative week. There was hypertrophy, restoring the ratio between left ven-
no difference between the two groups (P ⫽ 0.78). tricular mass and enddiastolic volume. The
increased rate of left ventricular enddiastolic volume
Echocardiographic data depends on the severity and nature of the regurgi-
At preoperative echocardiographic evaluation of all tation. The left ventricular endsystolic volume is also
patients, no significant differences between the two increased, but with considerable individual variation
groups were observed (Table 2). [15]. The effect of mitral regurgitation on the hemo-

60 CARDIOVASCULAR SURGERY FEBRUARY 2001 VOL 9 NO 1

 Posterior leaflet preservation in rheumatic mitral insufficiency: Kaan Kırali et al.

Table 2 Results of preoperative echocardiography and comparison of the left heart dimensions between groups

MVR–PCP MVR–CT P

LAD (cm) 5.33 ⫾ 0.87 (4.1–7) 5.1 ⫾ 1.15 (2.3–7.5) 0.54

LVESD (cm) 3.84 ⫾ 0.75 (2.8–5.2) 4.09 ⫾ 0.76 (2.7–6.6) 0.32
LVEDD (cm) 5.85 ⫾ 0.9 (4.6–7.3) 6.02 ⫾ 0.9 (4.2–8.7) 0.59
FS 34.2 ⫾ 7.4 (18–44) 32.1 ⫾ 5.2 (22–45) 0.29
LVESV (ml) 66.85 ⫾ 30.7 (30–129) 77.7 ⫾ 36.5 (27–224) 0.35
LVEDV (ml) 175.8 ⫾ 62.9 (97–280) 187.4 ⫾ 65.9 (79–415) 0.59
LVSV (ml) 108.9 ⫾ 44 (61–191) 110.2 ⫾ 35.9 (41–189) 0.92
LVFSV (ml) 82.8 ⫾ 39.9 (2–152) 83.1 ⫾ 28.2 (33–151) 0.98
EF (%) 62.3 ⫾ 10.3 (40–75) 59.3 ⫾ 7.7 (45–75) 0.29
FEF (%) 47.2 ⫾ 7.7 (30–60) 44.9 ⫾ 7.5 (35–60) 0.36

Table 3 Results of postoperative echocardiography and comparison of the left heart dimensions between groups

MVR–PCP MVR–CT P

LAD (cm) 4.72 ⫾ 1.2 (3.7–6.2) 4.46 ⫾ 1.23 (2.9–8) 0.71

LVESD (cm) 3.59 ⫾ 0.73 (2.7–5.2) 3.84 ⫾ 0.87 (2.5–6.5) 0.41
LVEDD (cm) 5.23 ⫾ 0.77 (4.3–6.6) 5.54 ⫾ 0.74 (4.1–7.2) 0.27
FS 31.6 ⫾ 8.2 (8–42) 31.1 ⫾ 6.6 (10–40) 0.85
LVESV (ml) 57.4 ⫾ 29.5 (27–129) 68.1 ⫾ 40.1 (22–216) 0.45
LVEDV (ml) 134.9 ⫾ 47.5 (83–224) 153.3 ⫾ 47.1 (74–272) 0.3
LVSV (ml) 76.5 ⫾ 30.4 (37–143) 85.2 ⫾ 19.7 (52–117) 0.32
EF (%) 57.1 ⫾ 12.3 (36–74) 57.8 ⫾ 10.9 (20–71) 0.86

dynamic balance depends on the intensity of regurgi-
tation and on the left atrial compliance. However,
severe regurgitation often produces minimal symp-
toms, but still results in a high incidence of left ven-
tricular dysfunction that might affect postoperative
survival [16]. The important predictive value of pre-
operative ejection fraction on late survival is consist-
ent with some series and they have shown that pre-
operative ejection fraction is the strongest predictor
of postoperative left ventricular function [17, 18].
Left ventricular ejection fraction falls significantly
after mitral valve replacement, especially after the
excision of the subvalvular apparatus [19]. If the
ejection fraction falls below 55% in severe mitral
regurgitation, it is a clear indication of left ventricu-
lar heart failure [20]. After correction of the mitral
regurgitation, a restoration of normal ventricular vol-
umes and a regression of hypertrophy are obtained
in the majority of patients.
In clinical practice EF is the most important
measurement, which determines left ventricular
function in pre- and postoperative period. In recent
studies the preoperatively ejection fraction of the
patients was 60.15 ⫾ 8.5%. After mitral valve
replacement EF did not decrease significantly and
was 57.6 ⫾ 11.1%. The normal range of FS is
between 25 and 35%. In our study FS decreased
from 32.7 ⫾ 5.9% to 31.2 ⫾ 6.9% in the postoper-
ative period, but it was not significant. Left ventricu-
lar systolic function was better in the postoperative
period, but improvement in the left ventricular dias-
tolic function after surgery was significant. Reduced
preload, indicated by the reduction in enddiastolic
volume, would have actually tended to reduce left
ventricular end diastolic diameter. Preservation of
the posterior leaflet did not improve the systolic
function compared with severed subvalvular appar-
atus. In spite of sudden reversal of the regurgitation
after mitral valve replacement increases the left ven-
tricular wall stress and may also impair left ventricu-
lar systolic function, it is not as important as patients
with normal EF, as in our study.
In most studies it has been reported that valve
repair protects left ventricular function better than
mitral valve replacement for chronic mitral insuf-
ficiency in the normal heart [21, 22]. On the other
hand, some reports have shown that mitral valve
replacement with preservation subvalvular apparatus
is superior to mitral valve replacement without pres-
ervation annulo-papillary continuity [3–7, 23–25]. In
recent studies, it has been showed that left ventricu-
lar performance is impaired following mitral valve
replacement in a normal heart with mitral regurgi-
tation after resection of subvalvular apparatus [5, 17,

CARDIOVASCULAR SURGERY FEBRUARY 2001 VOL 9 NO 1 61

Posterior leaflet preservation in rheumatic mitral insufficiency: Kaan Kırali et al.

Table 4 Results of echocardiography and comparison of the preoperative and postoperative data within groups. *Wilcoxon Signed Ranks Test

Preoperative Postoperative P

Total group
LAD (cm) 5.15 ⫾ 1.1 (2.3–7.5) 4.5 ⫾ 1.2 (2.9–8) 0.031
LVESD (cm) 4 ⫾ 0.8 (2.7–6.6) 3.8 ⫾ 0.8 (2.5–6.5) 0.013
LVEDD (cm) 5.9 ⫾ 0.9 (4.2–8.7) 5.4 ⫾ 0.7 (4.1–7.2) ⬍ 0.001
FS 32.7 ⫾ 5.9 (18–45) 31.3 ⫾ 6.9 (10–42) 0.45
LVESV (ml) 74.6 ⫾ 34.9 (27–224) 65.2 ⫾ 37.4 (22–216) 0.002
LVEDV (ml) 184.1 ⫾ 64.6 (79–415) 148.3 ⫾ 47.3 (74–272) ⬍ 0.001
LVSV (ml) 109.9 ⫾ 37.9 (41–191) 82.8 ⫾ 22.9 (37–143) ⬍ 0.001
LVFSV (ml) 83 ⫾ 31.5 (2–152) 82.8 ⫾ 22.9 (37–143) 0.92
EF (%) 60.1 ⫾ 8.5 (40–75) 57.6 ⫾ 11.1 (20–73) 0.28
FEF (%) 45.6 ⫾ 7.5 (30–60) 57.6 ⫾ 11.1 (20–73) ⬍ 0.001

MVR–PCP
LAD (cm) 5.33 ⫾ 0.87 (4.1–7) 4.72 ⫾ 1.2 (3.7–6.2) 0.46
LVESD (cm) 3.84 ⫾ 0.75 (2.8–5.2) 3.59 ⫾ 0.73 (2.7–5.2) 0.17
LVEDD (cm) 5.85 ⫾ 0.9 (4.6–7.3) 5.23 ⫾ 0.77 (4.3–6.6) 0.005
FS 34.3 ⫾ 7.6 (20–44) 32.4 ⫾ 8.2 (10–42) 0.835
LVESV (ml) 66.85 ⫾ 30.7 (30–129) 57.4 ⫾ 29.5 (27–129) 0.192
LVSV (ml) 108.9 ⫾ 44 (61–191) 76.5 ⫾ 30.4 (37–143) 0.005
LVEDV (ml) 175.8 ⫾ 62.9 (97–280) 134.9 ⫾ 47.5 (83–224) 0.005
LVFSV (ml) 82.8 ⫾ 39.9 (2–152) 76.5 ⫾ 30.4 (37–143) 0.65
EF (%) 62.3 ⫾ 10.3 (40–75) 57.1 ⫾ 12.3 (36–74) 0.575
FEF (%) 47.2 ⫾ 7.7 (30–60) 57.1 ⫾ 12.3 (36–74) ⬍ 0.001

MVR–CT
LAD (cm) 5.1 ⫾ 1.15 (2.3–7.5) 4.46 ⫾ 1.23 (2.9–8) 0.064
LVESD (cm) 4.09 ⫾ 0.76 (2.7–6.6) 3.84 ⫾ 0.87 (2.5–6.5) 0.003
LVEDD (cm) 6.02 ⫾ 0.9 (4.2–8.7) 5.54 ⫾ 0.74 (4.1–7.2) 0.001
FS 32.1 ⫾ 5.2 (22–45) 31.1 ⫾ 6.6 (10–40) 0.41
LVESV (ml) 77.7 ⫾ 36.5 (27–224) 68.1 ⫾ 40.1 (22–216) 0.003
LVEDV (ml) 187.4 ⫾ 65.9 (79–415) 153.3 ⫾ 47.1 (74–272) 0.001
LVSV (ml) 110.2 ⫾ 35.9 (41–189) 85.2 ⫾ 19.7 (52–117) ⬍ 0.001
LVFSV (ml) 83.1 ⫾ 28.2 (33–151) 85.2 ⫾ 19.7 (52–117) 0.87
EF (%) 59.3 ⫾ 7.7 (45–75) 57.8 ⫾ 10.9 (20–71) 0.32
FEF (%) 44.9 ⫾ 7.5 (35–60) 57.8 ⫾ 10.9 (20–71) ⬍ 0.001

22–24]. Reduced functional performance is attri-
buted to the immediate increase in afterload that
accompanies the abolition of the low-impedance
pathway for ejection into the left atrium and to ven-
tricular dysfunction caused by disruption of the
mitral valve apparatus. In contrast, valve replace-
ment with preservation of subvalvular apparatus
does not result in this fall in postoperative ejection
performance. In spite of the beneficial effect of pres-
ervation all subvalvular apparatus on the left ven-
tricular function has been well established, the effect
of only posterior leaflet preservation in chronic
mitral insufficiency is disputatious. Some authors
have shown that mitral valve replacement with the
preservation of the posterior leaflet appeared to be
important for both early and long-term left ventricu-
lar function [14]. They found that there was no dif-
ference in hospital mortality, but preservation of the
posterior leaflet increased exercise tolerance. On the
other hand, it was reported that posterior chordal
preservation did not increase the life expectancy in
high-risk patients [26]. However, we observed in this
study that the correction of severe mitral regurgi-
tation in patients without left ventricular dysfunction
was the most important factor to protect of left ven-
tricular function after mitral valve replacement, and
to preserve posterior leaflet had no adverse effect on
the left ventricular function. Our clinical data for
group A revealed no improvement in EF and FS.
Thus, it was suggested that preservation of posterior
leaflet alone did not have a beneficial effect on the
preservation of global cardiac function compared
with severed subvalvular apparatus. Long-term sur-
vival was not different in each group and the correc-
tion of mitral regurgitation caused this excellent sur-
vival.
In conclusion, to preserve posterior chordae tendi-
neae alone is not enough to improve global left ven-
tricular function after mitral valve replacement.
However, mitral valve replacement without chordal

62 CARDIOVASCULAR SURGERY FEBRUARY 2001 VOL 9 NO 1

 Posterior leaflet preservation in rheumatic mitral insufficiency: Kaan Kırali et al.
preservation alone is an adequate procedure to pre-
serve left ventricular function at patients with normal
EF after surgery.
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Paper accepted 12 July 2000
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