HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Bernard Eisenmann Arnaud Charpentier Sorin Popescu Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Eisenmann, B. Articles by Jirari, A. Search for Related Content PubMed PubMed Citation Articles by Eisenmann, B. Articles by Jirari, A.

Eur J Cardiothorac Surg 1998;14:584-589
© 1998 Elsevier Science NL

Is a prosthetic ring required for mitral repair of mitral insufficiency due to posterior leaflet prolapse? Long-term results in 96 patients submitted to repair with no ring¹

University Hospital, Department of Cardio-Vascular Surgery, B.P.426, F. 67091 Strasbourg, France

Received 28 September 1998; accepted 6 October 1998.

Corresponding author. Tel.: +33-3-8811-6243; fax: +33-3-8811-6342.

	Abstract

Top Abstract Introduction Material and methods Results Comments Conclusion Appendix A. Conference... References

 
Objective: It is a common statement that every mitral repair should be stabilized by some type of prosthetic mitral ring. In the very specific situation of isolated prolapse of the posterior leaflet (PPL), this statement may be enhanced by the possible anatomically discontinuity of the mitral annulus. This article concerns 96 patients with `isolated' PPL (IPPL) who were operated upon without ring insertion. Long-term follow-up was obtained in order to ascertain the survival, stability of the repair and the need for reoperation, thus justifying or not the lack of use of a ring. Methods: A total of 96 patients, 70 male and 26 female, underwent mitral repair for mitral insufficiency (MI) almost exclusively caused by PPL. Age ranged from 33 to 81 years (mean 60.7±11.3). All underwent quadrangular resection of the prolapsed portion and plication of the annulus. In 69 cases local stabilization was achieved by four U stiches, two on each side of the plication, passed through and sutured on some flexible material, 2–3 cm in length. Twenty seven patients had no such local reinforcement. Results: There was one case of early death (1%) caused by refractory hypoxemia in a patient with long lasting pre-operative pulmonary edema. Two patients were lost for follow-up after 2 months. Follow-up was from 0.2 to 14.7 years (mean 4.5), for a total of 422.7 patient-years. There were four late deaths at a mean of 6-year follow-up (0.9–10 years). Actuarial survival was 95.5 and 90.5% at 5 and 8 years, respectively. Event-free for recurrence of significant mitral insufficiency (MI) was 96 and 92% at 5 and 8 years. Event-free of thromboembolic or hemorrhagic events was 84.3 and 72.3% at 5 and 8 years. Event-free from reoperation was 97.8 and 94% at 5 and 8 years. Conclusion: One can conclude that (a) IPPL repair without insertion of a ring is safe and long-lasting (b) the incidence of late death, recurrence of MI, thromboembolic/hemorrhagic events, need for reoperation, is not higher in this subset of patients than in conventional repair (c) such repair might work better and for a longer time, as reaction and sclerosis resulting from ring insertion are avoided (d) minor advantages could be due to an easier surgical procedure, especially through a minimally invasive approach.

Key Words: Cardiac surgery • Mitral insufficiency • Mitral valve repair • Surgical technique • Ring

	Introduction

Top Abstract Introduction Material and methods Results Comments Conclusion Appendix A. Conference... References

 
That surgical outcome in mitral regurgitation is better after repair than after replacement [1] [2] is well documented by many reports. Preservation of the subvalvular apparatus [3] [4] results in better left ventricular function, and explains the surgical efforts to safeguard as much as possible the physiology of the mitral complex. Today, most surgeons use as a part of the repair a ring, in order to `reshape and resize a dilated annulus, improve leaflet coaptation and prevent recurrent or progressive dilatation'.

A number of devices have been designed to meet the aformentioned requirements, either by a rigid ring or by a partially or fully flexible device to maintain annulus flexibility and motion. However, there is a number of mitral regurgitations where there is only minimal or trivial annulus dilatation. This is the case in many patients with isolated prolapse of the posterior leaflet (IPPL) as is seen in myxomatous degeneration. As the defect accounting for the insufficiency appeared very localized, we assumed there is no need for a ring to be used, once the responsible defect is cured and leaflet coaptation restored. This report analyses the long-term follow-up of this series in order to support the assumption.

	Material and methods

Top Abstract Introduction Material and methods Results Comments Conclusion Appendix A. Conference... References

 
Between December 1981 and February 1996, all patients with isolated posterior valve prolapse were tentatively submitted to repair without insertion of a ring. Ninety-six patients had a successfull repair as described later, representing 90% of submitted cases, 75% carried out by one senior surgeon. Only those with isolated PPL were included in this study, in order to have an homogeneous subset of patients, referred as having had a `simple repair'.Nearly all regurgitations were secondary to myxomatous degeneration: obvious in 88 cases, possible in seven remaining cases. The last one could possibly be rheumatic in origin.

The repair consisted in resection of the flail portion of the prolapsed valve, and plication of the posterior annulus. They represent nearly 40% of all patients submitted to repair. All those who required implantation of a ring, leaflet transfer, chordal shortening, or neo chordae, were excluded. Patients with significant aortic valve involvement were also excluded from this series.

There were 70 males and 26 females. Mean age was 60.7±11.3 years ranging from 33 to 81 years, and 20 patients were 70 or older. Fifty-seven patients (60%) were in New York Heart Association (NYHA) functional 3 or 4 class; two were on mechanical ventilation at the time of operation. Sinus rhythm was recorded in 73 patients, 23 had arrhythmia. Mean ejection fraction was 63.6±9.4% with only eight patients having less than 50% ejection fraction. All underwent preoperative coronary angiography, 11 patients had ischemic coronary disease, eight underwent concomitant CABG. A small grade aortic insufficiency was present in 13 patients. Ten patients had a history of previous endocarditis, which was never active at time of operation. The repair consisted in the resection of the flail portion of the prolapsed valve, and plication of the posterior annulus.

In all patients an as simple as possible surgical procedure was carried out. It included quadrangular (in one case double quadrangular) resection of the prolapsed portion of the posterior leaflet, and plication (reinforced on pledgets) of the corresponding portion of the mural annulus. This technique was used in 27 patients. If there was a larger plication needed by the resection, (usually more than 15 mm of the extent of the annulus), sustained traction may be applied on the annular plication line and could result in suture dehiscence. Then the repair was reinforced by a localized annuloplasty obtained by suturing a small strip of tissue, (2–3 cm in length) through the annulus on both sides of the plication. The strip was cut out of a snare, most often from a Gore-Tex® vascular prosthesis. The posterior annuloplasty reinforcement technique was used in 69 patients.

In a few cases, marginal techniques were added (Table 1) as two cases of annular decalcification in order to allow the plication of the annulus after quadragular resection.

All patients were post-operatively given anticoagulation therapy with warfarine. Anticoagulants were given during the early years for 2 months and since 3 years they were given for up to 6 months, even in patients in sinus rhythm. Patients in atrial fibrillation were given anticoagulants indefinitely.

Data were obtained by in-hospital examinations of the patients or from those collected from their cardiologists. Functional and echocardiographic data were obtained in 81 patients. Regurgitation was graded from 0 to 4 by color-flow and pulsed-wave Doppler measurements. Grade 3 and 4 were accepted as significant regurgitation for considering reoperation.

Statistical Analysis
Patient characteristics are summarized with percentages for category data and with mean±standard deviation for continuous data. Due to the small samples in some subgroups, results were recalculated by Fischer's exact test. Multivariate analysis was assessed by logistic regression. Life time analysis of post-operative events such as death, thromboembolism,endocarditis, reoperations were calculated with the Kaplan–Meier's method. A probability value less than 0.05 was considered significant.

Factors assessed were: age>69-years old (n=20), NYHA functional class III and IV (n=57), LV ejection fraction <50% (n=8), concomitant ischemic heart disease (n=11), heart rhythm (arrhythmia n=23), type of posterior annuloplasty (without annular strip n=27). Univariate and multivariate analysis were used to determine their significance on early- and late-death and on all post-operative events taken as a whole.

The SOLO® statistical software package from BMDP was used for statistical computation.

	Results

Top Abstract Introduction Material and methods Results Comments Conclusion Appendix A. Conference... References

 
The follow-up was 98% complete as two patients were lost for follow-up at the 2nd post-operative month. Follow-up duration ranged from 0.2 to 14.7 years, for a total of 422.7 patients years; average follow-up was 4.5 years.

The 30-day mortality was 1% (1 of 96 patients). This patient was a 72-year-old woman, who had been suffering for bilateral pulmonary edema for many weeks. She was operated on while on mechanical ventilation and on intra-aortic balloon counterpulsation. Despite a good mitral repair and excellent cardiac function, she died on the 30th post-operative day due to refractory pulmonary hypoxia.

There were four late deaths, at a mean duration of 6 years (0.9–10 years). They were due to: (i) myocardial failure in a 85-year-old woman, 10 years after mitral repair (ii) myocardial failure occuring 10 months after repair (iii) sudden death at 8 years (iv) malignancy by melanoma at 4 years.

Three deaths were valve-related, and myocardial failure was the main cause of death, especially if the sudden death is included in that category. No predictive factor of early or late death could be identified either by univariate or multivariate analysis, due to the small number of events. Therefore, all valve-related events (death, mitral insufficiency and thromboembolic episodes) were aggregated and plotted against the variables. No correlation could be found (Table 2).

There were eight thromboembolic and two hemorrhagic events. One patient sustained a transient ischemic attack (TIA) 2 months post-operatively. This patient had had reinforcement of the annulus plication by a string of Gore-Tex®. All but one were fully regressive. Two occured early (at 2 months post-op). The others occured later on, between the 1st and 5th post-operative years. Four patients were in sinus rhythm while six presented with arrhythmia.

No post-operative endocarditis was observed. There was neither hemolysis reported in this series, nor mitral stenosis, nor again left ventricular outflow tract obstruction.

Linearized rates of post-operative events were:0.9%/year for late mortality, 0.5%/year for late reoperation, 2.3%/year for late thromboembolic or hemorrhagic events, 0%/year for late endocarditis, 0.7%/year for late recurrent mitral insufficieny.

Survival
Overall actuarial survival was 95.5%±2.7 at 5 years and 90.5%±5.5 at 8 years ( Fig. 1 ). The actuarial rate of recurrence-free from significant MR was 96.2±2.6% at 5 years and 92.6±4.3% at 8 years ( Fig. 2 ), reoperation-free actuarial rate for reoperation on mitral valve was 97.8±2.1% at 5 years and 94.2±4.1% at 8 years. Fig. 3 , event-free actuarial rate for thromboembolic or hemorrhagic events was 84.3±4.3% at 5 years and 72.3±11.9% at 8 years ( Fig. 4 ), for endocarditis 100% at 5 years and later. Actuarial rate of event-free from any possible valve related complication was 80.5% at 5 years and 65.8% at 8 years.

View larger version (12K): [in this window] [in a new window]   Fig. 1. Actuarial survival. *Number of patients at risk during the intervals.

View larger version (12K): [in this window] [in a new window]   Fig. 2. Actuarial freedom from recurrent significant mitral insufficiency. *Number of patients at risk during the intervals.

View larger version (12K): [in this window] [in a new window]   Fig. 3. Actuarial freedom from reoperation for recurrent mitral insufficiency. *Number of patients at risk during the intervals.

View larger version (14K): [in this window] [in a new window]   Fig. 4. Freedom of hemorrhagic or thromboembolic events. *Number of patients at risk during the intervals.

	Comments

Top Abstract Introduction Material and methods Results Comments Conclusion Appendix A. Conference... References

Despite numerous studies, no significant improvement has been documented between the older rigid or the more recent flexible rings [13].The progressive loss of annular flexibility could be one of the suggested explanations, but until now has not yet been demonstrated. Flexibility is more long-lasting with some devices, and annular contraction could improve over time [13]. Therefore, the beneficial impact could be important only in patients with significant preoperative left ventricular dysfunction. According to the good results reported it may seem unnecessary to keep off a ring. However, these results are frequently based on mid-term studies and the possible drawbacks of a ring may only appear in a later phase.

In most of our mitral reoperations where a ring had been inserted during the first procedure (19 patients) one could clearly identify gross fibrosis and sometimes calcifications on the site of implantation; these changes overlapped significantly to the adjacent mitral leaflets. The precise role played by fibrosis in the ultimate failure of the primary repair has still to be defined, but it has a possible role.

Cerfolio [14] reports the recent experience of the Mayo Clinic with 49 reoperations after mitral valve repair. If there are some technical failures, in 32 patients the initial repair was intact and above all, there was fibrosis formation, thickening and calcifications involving the leaflets and in seven cases the annulus. In addition, the authors report that 41 patients showed on echocardiographic examination signs of (recurrent?) annular dilatation; and at least in some cases, it happened in the probable presence of a ring! Whether or not annulus involvment was determining, whether or not the primary aetiology was evolving cannot be established. It is also probable that the 2.7% reoperation rate may be higher, since not all of the 1500 patients with mitral repair were contacted. It seems, accordingly, that a ring may be detrimental in the long-term, and if there is not definite need for it, it might be discarded.

Our series consists only of the very special subset of patients presenting with myxomatous degeneration where the pathologic process is an isolated prolapse of the posterior leaflet. In those patients there is usually no obvious annular dilatation. Also leaflet coaptation appears generally satisfactory apart from the prolapsed section, and left ventricular function is also protected, though the patients may be in high grade functional class [13] [15] [16]. These patients are candidates for the very `simple operation'.

It may be stated in favor of the ring that in myxomatous degeneration the whole leaflet is sick, and if there is no gross dilatation of the annulus, such a dilatation may develop in the long run. Nevertheless, there is no difference in histological appearance of the annulus of myxomatous degeneration and that of a normal valve. In both cases, there is a frequent discontinuity of the annulus [17]. Though in isolated PPL as there is no other obvious cause of mitral regurgitation, no preventive action such as a mitral ring insertion can be taken and warrants the effects. The long-term results of the present series are in favor of this interpretation; it allows for a simplified operation. Cohn [18] found that in myxomatous degeneration patients receiving a ring are doing better than those without a ring. But his patients were often submitted to complex repair including techniques on the anterior leaflet and the chordae. Diffuse degeneration is a risk factor for late failure [15], possibly independent from the presence of a ring. Surprisingly in some cases of severe mitral dystrophy, it has been suggested not to insert a ring because of a tissue `being to fragile' [19]. Theoretically, these cases would have been the best indications of this procedure!

We stopped performing routine TEE after mitral repair. Although good results have been reported in patients with less than `echo-perfect' results after mitral repair [20], we are in favor of a quasi perfect repair to promote good long-term results. This may also account for the excellent long-term stability of this series after surgery and explain the lack of discrepancy between the intra-operative competence-test and the TEE during surgery. In other situations, TEE remains an invaluable tool. In a series of 309 patients [21], TEE could document intraoperatively 26 immediate failures (8%), ten incomplete corrections, ten left ventricular outflow tract obstructions (LVOTO), and six suture dehiscences which led to immediate surgical correction. We consider that in difficult or complex repairs including chordae shortening, leaflets transfers, and each time the repair appears unsatisfactory, performing a peroperative TEE remains mandatory.

Dehiscence of the ring does not occur rarely [14] [20]. If a ring is not required, it seems advisable to avoid implanting one. Occurence of LVOTO has raised much interest [22], and to some extent, remains an unclear situation, though it has been infrequently reported following the sliding technique, or in repairs without a ring [23]. In this series there was neither LVOTO nor hemolysis case [24].

One such patient presented with a TIA 2 months post-operatively. As the patient was in sinus rhythm, the reason may be clot formation on the intra-cardiac foreign material and embolization. Therefore, anticoagulation is now continued up to 6 months post-operatively, even in the presence of a sinus rhythm. It also raised the question played by intracardiac prosthetic material and that of the consistency of anticoagulation. In order to reduce the amount of foreign materiel and potential sites of thrombus formation, the strip has been discarded since February 1996 by a modification of the sliding technique [4]. The flail portion is resected, an appropriate incision along the remnants of the posterior leaflet on each side is made; and at each endpoint of the leaflet incision the annulus is plicated. By this way traction as well as the amount of foreign material is reduced. The posterior leaflet is easily reconstructed by continuous suture.

	Conclusion

Top Abstract Introduction Material and methods Results Comments Conclusion Appendix A. Conference... References

 
Although the series presented is a small one, it is characteristic of a significant subset of patients with mitral insufficiency due to isolated PPL. This easy surgical procedure allows for excellent results which remain stable during 8–10 years. That this fact will still be true during the second decade requires further follow-up.

	Footnotes

 
Presented at the 11th Annual Meeting of the European Association for Cardio-thoracic Surgery, Copenhagen, Denmark, September 28 – October 1, 1997.

	Appendix A. Conference discussion

Top Abstract Introduction Material and methods Results Comments Conclusion Appendix A. Conference... References

 
Dr I. Vanek (Prague, Czech Republic): Is there some correlation between the diameter of the annulus and not using the ring? Since in the case when the ring is too large, I would be afraid not to use the annuloplasty ring. Is there some correlation? Are you using your method in every case in posterior leaflet prolapse?

Dr Eisenmann: To tell you that the ring is not necessary in all undilated mitral annulus when you do repair, we try to use it in a special subset of patients. And in this subset of patients, we, at 10 years, had no deleterious effect of the absence of the ring. Maybe, that the ring is not necessary in other cases but I can't comment about that.

Dr A. Ashmeg (Jedda, Saudi Arabia): I think quite a few surgeons around the world do mitral valve repair with no ring. And one of them is actually Dr Yacoub in London, he's been using complex mitral repairs with no ring for many years. We have done 221 cases of mitral repair and in about 30% of them we used no ring, for mitral regurgitation. Recently we have done a redo for two cases who had complex mitral repair, 15 and 17 years ago. If those patients had rings put in at that time, it probably would have been very difficult to repeat a repair on them. Those two who I have put a ring on, it will probably unlikely that a third repair will be done in the future. But I think that is an important point. A patient who receives no ring has a chance of a re-repair in the long-term.

	References

Top Abstract Introduction Material and methods Results Comments Conclusion Appendix A. Conference... References

 

1. Yun K.L., Miller D.C. Mitral valve repair versus replacement. Cardiol Clin 1991;9:315-327.[Medline]
2. Enriquez-Sarano M., Schaff H.V., Orszulak T.A., Tajik A.J., Bailey K.R., Frye R.L. Valve repair improves the outcome of surgery for mitral regurgitation. A multivariate analysis. Circulation 1995;91:1022-1028.[Abstract/Free Full Text]
3. Okita Y., Miki S., Ueda Y., Tahata T., Sakai T., Matsuyama K. Comparative evaluation of left ventricular performance after mitral valve repair or valve replacement with or without chordal preservation. J Heart Valve Dis 1993;2:159-166.[Medline]
4. Perier P., Clausnizer B., Mistarz K. Carpentier `sliding leaflet' technique for repair of the mitral valve: early results. Ann Thorac Surg 1994;57:383-386.[Abstract]
5. Oe M., Asou T., Kawachi Y., Kishizaki K., Fukamachi K., Sunagawa K., Tokunaga K. Effects of preserving mitral apparatus on ventricular systolic function in mitral valve operations in dogs. J Thorac Cardiovasc Surg 1993;106:1138-1146.[Abstract]
6. Cosgrove D.M., Chavez A.M., Lytle B.W. Results of mitral valve reconstruction. Circulation 1986;74(Suppl. 1):82-87.
7. Deloche A., Iebara V.A., Relland J.Y., Chauvaud S., Fabiani J.N., Perier P., Dreyfus G., Mihaileanu S., Carpentier A. Valve repair with Carpentier techniques. The second decade. J Thorac Cardiovasc Surg 1990;99:990-1002.[Abstract]
8. Xu M., McHaffie D.J., Hilless A.D. Mitral valve repair: a clinical and echocardiographic study. Br Heart J 1994;71:51-56.[Abstract/Free Full Text]
9. Van Rijk-Zwikker G.L., Mast F., Schipperheyn J.J., Huysmans H.A., Bruschke A.V. Comparison of rigid and flexible rings for annuloplasty of the porcine mitral valve. Circulation 1990;82(Suppl. 5):58-64.
10. Rayhill S.C., Castro L.J., Niczyporuk M.A., Ingels N.B., Jr., Daughters G.T., Derby G.C., Tye T.L., Bolger A.F., Miller D.C. Rigid ring fixation of the mitral annulus does not impair left ventricular systolic function in the normal canine heart. Circulation 1992;86(Suppl. 2):26-38.
11. Castro L.J., Moon M.R., Rayhill S.C. Annuloplasty with flexible or rigid ring does not alter left ventricular systolic performance, energetics, or ventricular-arterial coupling in conscious closed-chest dogs. J Thorac Cardiovasc Surg 1993;105:643-658.[Abstract]
12. Ren J.F., Aksut S., Lighty G.W., Jr., Vigilante G.J., Sink J.D., Segal B.L., Hargrove W.C. III. Mitral valve repair is superior to valve replacement for the early preservation of cardiac function: relation of ventricular geometry to function. Am Heart J 1996;131:974-981.[Medline]
13. David T.E., Komeda M., Pollick C., Burns R.J. Mitral valve annuloplasty: the effect of the type on left ventricular function. Ann Thorac Surg 1989;47:524-527.[Abstract]
14. Cerfolio R.J., Orzulak T.A., Pluth J.R., Harmsen W.S., Schaff H.V. Reoperation after valve repair for mitral regurgitation: early and intermediate results. J Thorac Cardiovasc Surg 1996;111:1177-1183.[Abstract/Free Full Text]
15. David T.E., Armstrong S., Sun Z., Daniel L. Late results of mitral valve repair for mitral regurgitation due to degenerative disease. Ann Thorac Surg 1993;56:7-12.[Abstract]
16. Cohn L.H., Di Sesa V.J., Couper G.S., Peigh P.S., Kowalker W., Collins J.J., Jr. Mitral valve repair for myxomatous degeneration and prolapse of the mitral valve. J Thorac Cardiovasc Surg 1989;98:987-992.[Abstract]
17. Angelini A., Ho S.Y., Anderson R.H., Davies M.J., Becker A.E. A histological study of the atrioventricular junction in hearts with normal and prolapsed leaflets of the mitral valve. Br Heart J 1988;59:712-716.[Abstract/Free Full Text]
18. Cohn L.H., Couper G.S., Aranki S.F., Rizzo R.J., Kinchla N.M., Collins J.J., Jr. Long-term results of mitral valve reconstruction for regurgitation of the myxomatous mitral valve. J Thorac Cardiovasc Surg 1994;107:143-150.[Abstract/Free Full Text]
19. Unger-Graeber B., Lee R.T., Sutton M.S., Plappert M., Collins J.J., Cohn L.H. Doppler echocardiographic comparison of the Carpentier and Duran anuloplasty rings versus no ring after mitral valve repair for mitral regurgitation. Am J Cardiol 1991;67:517-519.[Medline]
20. Fix J, lsada L, Cosgrove D, Miller DP, Savage R, Blum J, Stewart, W. Do patients with less than `echo-perfect' results from mitral valve repair by intraoperative echocardiography have a different outcome? Circulation 1993; 88(5):II39–II48.
21. Marwick T.H., Stewart W.J., Currie P.J., Cosgrove D.M. Mechanisms of failure of mitral valve repair: an echocardiographic study. Am Heart J 1991;122:149-156.[Medline]
22. Freeman W.K., Schaff H.V., Khandheria B.K., Oh J.K., Orszulak T.A., Abel M.D. Intraoperative evaluation of mitral valve regurgitation and repair by transoesophageal echocardiography: incidence and significance of systolic anterior motion. J Am Coll Cardiol 1992;20:599-609.[Abstract]
23. Pasic M., Von Segesser L., Niederhauser U., Vogt P., Jenni R., Turina M. Outflow tract obstruction after mitral valve repair without an annuloplasty ring. Eur J Cardio-thorac Surg 1995;9:283-285.[Abstract]
24. Wilson J.H., Rath R., Glaser R., Panke T. Severe hemolysis after incomplete mitral valve repair. Ann Thorac Surg 1990;50:136-137.[Abstract]

This article has been cited by other articles:

				P. Fundaro, P. M Tartara, E. Villa, P. Fratto, S. Campisi, and E. O Vitali Mitral Valve Repair: Is There Still a Place for Suture Annuloplasty? Asian Cardiovasc Thorac Ann, August 1, 2007; 15(4): 351 - 358. [Abstract] [Full Text] [PDF]

				A. M. Calafiore, M. Di Mauro, A. L. Iaco, V. Mazzei, G. Teodori, S. Gallina, L. Weltert, M. Samoun, and G. Di Giammarco Overreduction of the Posterior Annulus in Surgical Treatment of Degenerative Mitral Regurgitation Ann. Thorac. Surg., April 1, 2006; 81(4): 1310 - 1316. [Abstract] [Full Text] [PDF]

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Bernard Eisenmann Arnaud Charpentier Sorin Popescu Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Eisenmann, B. Articles by Jirari, A. Search for Related Content PubMed PubMed Citation Articles by Eisenmann, B. Articles by Jirari, A.