Durability at 19 Years of Quadrangular Resection With Annular Plication for Mitral Regurgitation

Background: We report the long-term (19 years) clinical and echocardiographic results of the quadrangular resection with annular plication and annuloplasty. Methods: Included were 145 consecutive patients (mean age, 58 ± 11.1 years; left ventricular ejection fraction, 0.59 ± 0.095) with severe degenerative mitral regurgitation due to posterior leaflet prolapse/flail who underwent quadrangular resection of the posterior leaflet combined with ring (127 patients [87.5%]) or pericardium (18 patients [12.5%]) annuloplasty. Results: No hospital deaths occurred. At hospital discharge, all patients but 1 had none or trivial mitral regurgitation. Follow-up was 97% complete (median, 19 years; interquartile range, 18 to 20 years). At 20 years, the overall survival was 74% ± 3.7%. At 19 years, cumulative incidence function of cardiac death with noncardiac death as a competing risk was 9.9% ± 2.5% (95% confidence interval [CI], 5.7% to 15.5%). Age was the only significant predictor of cardiac death (hazard ratio, 1.1; 95% CI, 1.0 to 1.1; p = 0.01) at multivariate analysis. Only 6 patients (4%) were reoperated on for recurrent severe mitral regurgitation. At 19 years, cumulative incidence function of reoperation and recurrence of mitral regurgitation 3+ or higher with death as a competing risk was 4.3% ± 1.7% (95% CI, 1.7% to 8.8%) and 8.8% ± 2.8% (95% CI, 4.3% to 15.5%), respectively. Indeed, only 11 patients (8%) had recurrent mitral insufficiency 3+ or higher. No predictor of reoperation and recurrence of mitral regurgitation 3+ or higher was identified. At the last follow-up, moderate mitral regurgitation (2+/4+) was detected in 14 patients (10%). Conclusions: Quadrangular resection with annular plication for posterior leaflet prolapse, combined with annuloplasty, is associated with a very low probability of reoperation and recurrent mitral regurgitation for up to 2 decades after the operation. These results provide reference values to which all of the other more recently introduced surgical and transcatheter options need to be compared.