Ten-Year Results of Folding Plasty in Mitral
Valve Repair
Charles F. Schwartz, MD, Eugene A. Grossi, MD, Greg H. Ribakove, MD,
Patricia Ursomanno, PhD, Meg Mirabella, RN, Gregory A. Crooke, MD, and
Aubrey C. Galloway, MD
Department of Cardiothoracic Surgery, New York University School of Medicine, New York, New York
Background. Folding plasty (FP) for posterior mitral
leaflet repair (PLR) is a technique that reduces the height
of the repaired leaflet, closes the gap created by leaflet
resection by rotation of residual leaflet, and reduces the
need for localized annular plication. This report reviews
late outcomes with FP repair.
Methods. From January 1994 to August 2006, 1,402
mitral valve repairs were performed for degenerative
disease: 1,012 had PLR and 531 had FP technique.
Results. Overall hospital mortality was 2.4% (33 of
1,402 patients) and 1.3% (14 of 1,103 patients) for isolated
mitral repair. For those patients with PLR, mortality for
all procedures was 1.5% (15 of 1,012 patients) and 1.2%
(11 of 891 patients) for isolated PLR repairs. Mortality
was 0.9% (5 of 531 patients) for FP. In the last 5 years FP
D uring the last 15 years, it has been repeatedly
demonstrated and accepted that patients undergo-
ing mitral valve repair have fewer late valve-related
complications than patients having mitral valve replace-
ment [1]. This observation was subsequently confirmed
in more than 10 large series reviewed by Yun and Miller
[2]. Numerous advantages of valve repair include better
maintenance of left ventricular function, lower risks of
thromboembolism and anticoagulant-related complica-
tions, and reduced risk of endocarditis. Mitral valve
repair has therefore become the preferred treatment for
patients with mitral insufficiency from degenerative dis-
ease [3, 4]. The American Heart Association has recently
changed its guidelines to recommend earlier surgery in
patients with mitral insufficiency.
Lillehei and colleagues [5] introduced the concept of
valvuloplasty in 1957, with subsequent suture annulo-
plasty techniques developed by Reed and coworkers [6,
7] and Kay and associates [8, 9]. An improved approach
that began to address more complex leaflet pathology
was pioneered by Carpentier and colleagues [10, 11].
Subsequently, many have duplicated these techniques.
The standard operative technique for correcting a pro-
Accepted for publication Oct 23, 2009.
Presented at the Poster Session of the Forty-fourth Annual Meeting of
The Society of Thoracic Surgeons, Fort Lauderdale, FL, Jan 28 –30, 2008.
Address correspondence to Dr Grossi, Department of Cardiothoracic
Surgery, New York University Medical Center, 530 First Ave, Suite 9V,
New York, NY 10016; e-mail: grossi@cv.med.nyu.edu.
© 2010 by The Society of Thoracic Surgeons
Published by Elsevier Inc
ADULT CARDIAC
was used in 64.4% of PLR, compared with 35.6% of PLR
in the prior era (p < 0.001). The 10-year actuarial freedom
from mitral reoperation was 89%; 10-year freedom from
reoperation or recurrent severe mitral insufficiency was
86% with FP and 87% without (p ⴝ 0.76). The 5-year
freedom from reoperation or recurrent severe insuffi-
ciency was 89% when an annuloplasty device was used
and 62% when not used (p < 0.001).
Conclusions. Repair of posterior leaflet prolapse with
FP is straightforward and durable. In our experience, FP
is currently used for two thirds of PLR. These data also
confirm that valve repair for degenerative disease should
include an annuloplasty device for optimal late results.
(Ann Thorac Surg 2010;89:485–9)
© 2010 by The Society of Thoracic Surgeons
lapsed posterior leaflet includes quadrangular leaflet
resection and annular plication to bring the cut edges
into apposition [11]. This standard technique indeed
corrects the prolapsing defect but advances the line of
closure toward the anterior annulus.
Folding plasty (FP), an alternative technique for cor-
recting the defect after a posterior mitral leaflet resection,
was introduced by our group in 1998 [12]. Bilateral FP
involves folding down the cut vertical edges of the
posterior leaflet to the annulus and closing the ensuing
cleft. With this technique, the central height of the
posterior leaflet is reduced and the line of leaflet coapta-
tion is moved posteriorly. This study reviews late out-
comes with this approach.
Patients and Methods
This study was conducted with the approval of the New
York University School of Medicine institutional review
board with specific waiver of the need for individual
patient consent. Patient data were collected prospectively
using the definitions for preoperative risk factors and
perioperative complications used by the New York State
Cardiac Surgery Reporting System. Hospital mortality
was defined as death at any time before discharge from
the hospital. Standard follow-up includes annual clinical
contact and echocardiographic surveillance. Statistical
analysis was performed using the statistical software
SPSS (SPSS Inc, Chicago, IL). Categorical variables
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 486 SCHWARTZ ET AL Ann Thorac Surg
MITRAL FOLDING PLASTY 2010;89:485–9

Table 1. Demographic, Procedural, and Outcome Data for

Patients With Degenerative Mitral Insufficiency and
Posterior Leaflet Resection
Without With
Folding Folding p
ADULT CARDIAC

Variable Plasty Plasty Value

N 481 531
Age 62.3 ⫾ 15.2 58.2 ⫾ 13.9 0.001
Age 70 years or 188 (39.1%) 137 (25.8%) ⬍0.001
greater
Sex (male) 301 (62.6%) 363 (68.4%) 0.15
Preop NYHA class 2.3 ⫾ 0.8 2.1 ⫾ 0.5 0.001
Postop NYHA class 1.3 ⫾ 0.5 1.2 ⫾ 1.1 0.26
Mortality 10 (2.1%) 5 (0.9%) 0.13
Previous cardiac 27 (5.6%) 9 (1.7%) 0.001
surgery
Concomitant CABG 56 (11.6%) 23 (4.3%) ⬍0.001 Fig 2. Survival from mitral valve reoperation in patients with de-
Concomitant valve 34 (7.1%) 16 (3.0%) 0.003 generative disease and posterior leaflet resection; impact of folding
Operative approach 102 (21.2%) 50 (9.4%) ⬍0.001 plasty.
(sternotomy)
Annuloplasty 424 (88.1%) 513 (96.6%) ⬍0.001
the Wilcoxon statistic was used to test for survival
Anterior leaflet 129 (26.8%) 183 (34.4%) 0.01
procedure differences.
Perioperative 10 (2.1%) 16 (3.0%) 0.35
systolic anterior Patient Population
motion This analysis included all patients who underwent mitral
Perioperative MI 4 (0.8%) 4 (0.8%) 0.88 valve repair for degenerative causes in our institution.
Calendar year of 2000.3 ⫾ 3.5 2001.5 ⫾ 2.8 0.001 Between January 1994 and August 2006, 1,402 such valve
operation repairs were performed. Of these patients, 1,012 (72%)
had a posterior leaflet repair (PLR). Concomitant proce-
CABG ⫽ coronary artery bypass grafting; MI ⫽ myocardial infarction;
NYHA ⫽ New York Heart Association. dures included coronary artery bypass grafting (n ⫽ 79;
7.8%) and multivalve operations (n ⫽ 50; 4.9%).

were analyzed by the ␹2 test and continuous varia- Surgical Technique

bles with unpaired Student’s t test. A probability value of
less than 0.05 was considered to be significant. Life
table analysis was used to calculate late survival curves;
Fig 1. Illustration of a folding plasty technique. (A) Prolapsing seg-
ment. (B) After leaflet resection and starting to fold. (C) Fold com-
pleted and closing cleft. (D) Finished repair.
Quadrangular resection of the posterior leaflet has be-
come the mainstay of mitral repair for posterior leaflet
prolapse. Diseased tissue in the posterior leaflet is ex-
cised with a quadrangular excision, usually removing 2 to
4 cm of tissue, occasionally more than 50% of the poste-
rior leaflet. Strong chordae of proper lengths are identi-
fied on each side of the excised leaflet and encircled with
retraction sutures. After quadrangular excision is per-
formed down to the annulus, a decision is made as to
whether to proceed with annular plication and traditional
leaflet repair versus FP or occasionally sliding plasty as
described by Carpentier [11]. When the height of the
residual posterior leaflet is high (⬎1.5 cm) and the defect
resulting from leaflet resection can be closed by rotating
in residual leaflet tissue, the FP technique is our pre-
ferred method of repair. The edge of the residual cut
leaflet is folded (or rotated), and the vertical cut edges are
sutured to the annulus (Figs 1A, 1B). Once the defect in
the annulus is corrected with the folded leaflet, the re-
sidual leaflet tissue is sutured together, completing the
repair (Figs 1C, 1D). In this way the central height of the
posterior mitral leaflet is reduced, and the line of coap-
tation between the anterior and posterior leaflet is moved
posteriorly. In this way, the need for annular plication is
obviated or reduced.
An annuloplasty device is recommended in the vast
Ann Thorac Surg
2010;89:485–9
Fig 3. Survival from mitral valve reoperation or severe mitral regur-
gitation in patients with degenerative disease, posterior leaflet resec-
tion, and device annuloplasty; impact of folding plasty.
majority of patients. The basic principle of annuloplasty
is restoration of the geometric shape of the mitral orifice,
to correct annular dilation, and to hold the leaflets in a
slightly convex configuration, improving leaflet coapta-
tion and lowering tension on the repair. Although some
debate remains regarding the best type of annuloplasty,
studies suggest that repair without the use of an annu-
loplasty contributes to late repair failures [13, 14].
Results
The FP technique was used to correct the leaflet deficit in
531 (52%) cases of PLR. Hospital mortality was 1.3% (14 of
1,103) for isolated mitral repair and overall mortality was
2.4% (33 of 1,402). In all patients with PLR mortality was
1.5% (15 of 1,012) and 1.2% (11 of 891) for isolated repairs.
Mortality was 0.9% (5 of 531) for those with FP. In the last
5 years, 64.4% of PLR used FP, compared with 35.6% in
the prior era (p ⬍ 0.001).
Table 1 contains the demographic, procedural, and
outcome data for all patients undergoing posterior leaflet
resection. For all PLR, perioperative myocardial infarc-
tion occurred in 0.8% with FP and 0.8% of patients
without (p ⫽ 0.88). Systolic anterior motion occurred in
2.6% of PLR (3.0% with FP and 2.1% without; p ⫽ 0.35).
The actuarial 10-year freedom from mitral reoperation
in device annuloplasty patients was 89% (Fig 2). The
10-year freedom from either reoperation or recurrent
severe mitral insufficiency in patients with posterior
resection and device annuloplasty was 86% with FP and
87% without (p ⫽ 0.31; Fig 3). A small percentage of the
patients (7.4%; 75 of 1,012) did not receive an annulo-
plasty device with their repair. The majority of this
occurred in the mid 1990s coincident with the initial
nonsternotomy approaches. The 5-year freedom from
reoperation was 94% when an annuloplasty device was
used and 80% when an annuloplasty device was not used
(p ⫽ 0.001; Fig 4). The 5-year freedom from reoperation or
SCHWARTZ ET AL 487
MITRAL FOLDING PLASTY
recurrent severe insufficiency was 89% when an annulo-
plasty device was used and 62% when not used (p ⬍ 0.001).
Comment
ADULT CARDIAC
Since the first publication of the posterior leaflet FP
technique in 1998 [12], the technique has been increas-
ingly used for repair of posterior leaflet disease. This
technique is always useful in Barlow’s type valves, in
which there is significant residual height to the posterior
leaflet after resection of the leaflet disease. In this situa-
tion, a classic repair of posterior annular plication fol-
lowed by leaflet repair would elevate the height of the
residual repaired leaflet, resulting in a high plane of
coaptation between the anterior and posterior leaflets,
increasing the risk of postrepair systolic anterior motion
(SAM). Thus, one of the original goals of FP was to lower
the incidence of SAM after repair of Barlow’s type
disease. Although the incidence of SAM with or without
FP was not different in this report, it should be noted that
the indication for use of the FP technique was a high
residual height to the posterior leaflet (⬎1.5 to 2 cm
height of residual posterior leaflet), most commonly seen
with Barlow’s type disease. This group is the subset of
patients undergoing PLR who are most likely to experi-
ence SAM, a group often treated by others with the
sliding plasty technique [15]. Traditional repair with
annular plication was used instead of FP in this series,
primarily in patients with fibroelastic deficiency in which
the height of residual posterior leaflet is short and the
expected closure plane more inferior on the anterior
leaflet. The risk of SAM in these patients is inherently
lower. Thus, the use of FP may have theoretically lowered
the risk of SAM in the subset of Barlow’s patients in
whom the technique was used.
Since publishing early results with the FP technique in
1998 [12], many variations have evolved. Folding plasty
has been combined with annular plication in the repair of
a large prolapsing posterior leaflet with excessive height
and in cases of commissural prolapse, involving both
Fig 4. Survival from mitral valve reoperation; impact of annulo-
plasty device.
 488 SCHWARTZ ET AL
MITRAL FOLDING PLASTY
anterior and posterior leaflets [16]. The authors used
unilateral FP in cases involving different lengths of the
cut edges on the two leaflets. Morimoto and associates
[17] used FP techniques for repair of extended commis-
sural prolapse involving either or both of the anterior and
ADULT CARDIAC
posterior leaflets. Da Col and colleagues [18] reported yet
another variation of this technique along with a triangu-
lar resection of the posterior leaflet. Additionally, FP
techniques have been reported in complex repairs of
Barlow’s disease [19]. In these cases, plication of the
annulus was followed by a combined sliding leaflet and
FP to create a new posterior leaflet. Recently, a derivative
of this procedure was reported by Miheljevic and co-
workers [20]. This approach described folding the poste-
rior leaflet underneath itself, without leaflet resection,
thus reducing the height of the posterior segment.
An additional benefit of FP is the avoidance of injury to
a large circumflex artery in the atrioventricular groove
that may result from annular plication [12]. There were
no circumflex artery injuries noted in this series.
Long-term durability remains the most important tenet
of mitral valve repair. In this study, FP repair was
durable, with 87% of patients remaining free of reopera-
tion or recurrent severe mitral insufficiency at 10 years.
Thus the technique has excellent long-term durability.
The FP technique for PLR is a straightforward, useful
technique that results in excellent late repair durability.
Folding plasty repair is especially useful in patients with
Barlow’s type disease and in others with significant residual
height to the posterior leaflet. Folding plasty is an attractive
option to sliding plasty in this subset of patients and may
minimize the risk of SAM in this high-risk group.
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© 2010 by The Society of Thoracic Surgeons
Published by Elsevier Inc
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centage of patients who receive the best therapy (ie, valve
repair) requires the development of a suite of simpler,
more accessible surgical techniques.
With the creation of folding plasty, Schwartz and
coworkers [1] take an important step in this direction.
The folding plasty effectively replaces the more complex
sliding repair. Applied after posterior leaflet resection,
when the remaining leaflet edges are tall (⬎ 1.5 cm),
folding plasty reduces posterior leaflet height, helping to
avoid the problem of SAM. It is noteworthy that surgeons
at New York University now use this technique in nearly
two thirds of their patients with posterior leaflet
prolapse.
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