Minimally invasive mitral valve repair: Ten-year outcomes of the “Re-Lock technique” for complex bileaflet mitral valve disease

The objective was to evaluate the 10-year clinical and echocardiographic outcomes of minimally invasive Re-Lock mitral valve repair for Barlow-type or complex bileaflet degenerative disease, evaluating overall survival, freedom from mitral regurgitation 2+ or greater, need for reoperation, and New York Heart Associaton class. From 2008 to 2016, 140 consecutive patients with Barlow-type degenerative bileaflet mitral valve disease underwent video-assisted minimally invasive right anterolateral thoracotomy repair at a single institution. In all cases, the repair was based on the Re-Lock maneuver. Patients were classified according to the need for anterior intervention. Group 1 included patients receiving Re-Lock only (n = 33), in whom anterior billowing or mild prolapse became competent after posterior correction and required no additional repair. Group 2 included patients receiving Re-Lock + anterior expanded polytetrafluoroethylene neochordae (n = 107), in whom true anterior prolapse or flail warranted targeted neochordal implantation. Follow-up was completed through scheduled clinical and echocardiographic evaluations, with a median duration of 10.2 years. Technical success with freedom of mitral regurgitation (mild or less on intraoperative transesophageal echocardiography) was 99.3%, with no 30-day mortality. At 10 years, overall survival was 95.7%. Freedom from mitral regurgitation 2+ or greater was 91.2%, and freedom from reoperation was 96.4%. Postoperative New York Heart Association class improved in 130 of 140 patients (92.9%) and maintained class I at last follow-up in 122 of 130 survivors (93.8%). No statistically significant difference was observed in outcomes by technique group (log-rank P = .74). A learning curve was evident, with crossclamp time decreasing from 69.7 ± 11.9 to 45.3 ± 10.4 minutes over time. The minimally invasive Re-Lock technique provides safe, reproducible, and effective long-term results for complex bileaflet mitral valve disease, including Barlow's pathology. Re-Lock in bileaflet degenerative MR. A, Prerepair assessment of bileaflet degenerative MR with billowing/pseudoprolapse and annular dilatation. B, Posterior leaflet relocation with “locking” sutures to eliminate excess height and abolish functional pseudoprolapse; sliding annuloplasty as needed for height control. C, Ring sizing and implantation to restore annular geometry and stabilize coaptation. D, Selective anterior ePTFE neochordae when predefined criteria are met, targeting a coaptation length 8 mm or more and durable competence. ePTFE , Expanded polytetrafluoroethylene; MR , mitral regurgitation.