Table 3. Likelihood of repair and surgical implications according to valve analysis in a heart valve centre with an experienced surgeon.
| Etiology | Dysfunction | Lesion | Suitability of repair/surgical implications |
|---|---|---|---|
| Organic | Suitability of repair & surgical implications | ||
| Degenerative | |||
| All phenotypes | Type II (prolapse): any leaflet (posterior and/or anterior) and any scallops involved (P1/P2/P3–A1/A2/A3) including commissures and/or indentations | Chordal rupture and/or elongation | Optimal repair: with all surgical techniques available (resection and/or Gore-Tex) but with systematic ring annuloplasty |
| No or localized calcification | |||
| Favorable amount and quality of tissue | |||
| Annular dilatation | |||
| FED | Type II (prolapse) | Fragility of tissue +++ | Challenging repair: valve replacement if leaflet too fragile and/or extensive annular calcification and protrusion into LV |
| Calcifications: leaflet and/or annulus | |||
| Barlow | Specific pattern: dynamic functional prolapse involving all scallops with a central color jet | Mitral annular disjunction with rocking/curling motion of posterior annulus and PM stretching | Optimal repair: sole and large annuloplasty ring (usually size 40 mm) with or without reduction of height of posterior leaflet to avoid SAM |
| Excess of posterior leaflet (>20 mm) | |||
| Endocarditis | Type I | Perforation | Optimal repair: patch |
| Type II | Numerous chordal ruptures with extensive infected leaflet tissue and/or annular abscess | Challenging repair: if early phase: repair possible. If late surgery and lack of non-infected tissue after resection of infected lesions: prefer valve replacement | |
| Rheumatic | Type III posterior ± type II anterior | Retraction and/or stiff anterior leaflet | Challenging repair: repair possible with patch leaflet extension and/or “shaving” of the anterior leaflet. If stiff and calcified anterior leaflet and/or severe sub-valvular apparatus retraction and fused: prefer valve replacement |
| Retracted, fused & short chordae | |||
| Calcification involving leaflet and/or sub valvular apparatus | |||
| Functional | Surgical implications | ||
| Ventricular | Type IIIb (chronic) | Moderate LV dilation (EDD <65 mm and/or ESD <41 mm) and tenting area (<2.5 cm2) | Optimal repair with undersized annuloplasty (2 sizes) with no MR and coaptation ≥8 mm |
| Note: if posterior PM displacement only (IIIbP3) favor ischemic ring annuloplasty (undersized on P3) | |||
| Severe LV dilation (EDD >65 mm and/or ESD >41 mm) and tenting area (>2.5 cm2) | Challenging repair: high risk of recurrent MR, prefer valve replacement | ||
| Type II (acute) | PM rupture | Challenging repair: unstable patients in cardiogenic shock: prefer valve replacement | |
| Type II (chronic) | PM elongation, particularly posterior PM | Optimal repair (PM repositioning) | |
| Atrial | Type I | Annular dilatation | Optimal repair (isolated ring annuloplasty) |
EDD, end-diastolic diameter; ESD, end-systolic diameter; LV, left ventricle; MR, mitral regurgitation; PM, papillary muscle; SAM, systolic anterior motion.