Reoperative Mitral Valve Replacement: Importance
of Preservation of the Subvalvular Apparatus
Michael A. Borger, MD, PhD, Terrence M. Yau, MD, MS, Vivek Rao, MD, PhD,
Hugh E. Scully, MD, and Tirone E. David, MD
Division of Cardiovascular Surgery, Toronto General Hospital, University Health Network, and Department of Surgery, University
of Toronto, Toronto, Ontario, Canada
Background. Preservation of the subvalvular apparatus
has been demonstrated to be beneficial during first-time
mitral valve replacement (MVR), but has not been fully
examined in reoperative (redo) MVR. The purpose of this
study was to analyze outcomes in a large cohort of redo
MVR patients, focusing on the effect of subvalvular
preservation on mortality.
Methods. We undertook a review of prospectively
gathered data on patients undergoing MVR, with or
without concomitant cardiac procedures, at our institu-
tion from 1990 to 1999. Predictors of mortality were
determined by stepwise logistic regression.
Results. A total of 1,521 consecutive MVR patients
were analyzed, of which, 513 (34%) had undergone one or
more previous MV procedures. In-hospital mortality oc-
curred in 6.9% of first-time MVR patients versus 9.0% in
redo patients (p ⴝ 0.13). The number of prior MV
operations ranged from one to five in redo MVR patients,
with 115 patients (22% of redos) having two or more. In
redo MVR patients, preservation of the native posterior
subvalvular apparatus was performed in 103 patients
I t has been well demonstrated that preservation of the
subvalvular apparatus during first-time mitral valve
replacement (MVR) is associated with improved clinical
outcomes. We have previously shown that preserved
annular-papillary continuity results in improved left ven-
tricular function in the early [1–3] and late [1] postoper-
ative period, as well as improved short-term [4] and
long-term [4, 5] survival post-MVR. Other investigators
have confirmed the beneficial effects of subvalvular pres-
ervation on left ventricular function [6 – 8], symptomatol-
ogy [6], and survival [7, 9] after MVR.
Reoperative (redo) mitral valve surgery is a common
clinical problem. Bioprosthetic valves, in particular, com-
monly require re-replacement because of their predispo-
sition to structural deterioration [10]. As long-term sur-
vival improves after mitral valve surgery, the incidence of
redo MVR may be increasing over time. Relatively few
studies have examined the results of reoperative MVR,
consisting mostly of single-institution retrospective case
Accepted for publication June 26, 2002.
Address reprint requests to Dr Borger, Toronto General Hospital, Room
CN13-222, 200 Elizabeth St, Toronto, Ontario, Canada M5G 2C4; e-mail:
michael.borger@utoronto.ca.
© 2002 by The Society of Thoracic Surgeons
Published by Elsevier Science Inc
(21%), whereas native anterior and posterior preservation
was performed in 31 patients (6%). Gore-Tex neochordal
construction was performed in 135 redo MVR patients
(26%). Perioperative mortality occurred in 3.6% of redo
MVR patients with a preserved subvalvular apparatus
(native tissue and/or Gore-Tex reconstruction) versus
13.3% of redo patients without preservation (p < 0.001).
Independent predictors of mortality in redo MVR pa-
tients were (in decreasing order of magnitude) failure to
preserve the subvalvular apparatus, preoperative renal
failure, previous stroke/transient ischemic attack, left
ventricular dysfunction (left ventricular ejection fraction
<40%), and urgent timing.
Conclusions. Redo MVR can be performed with an
acceptable risk of mortality. Although preservation of the
subvalvular apparatus may increase operative complex-
ity, we recommend subvalvular preservation in order to
decrease the risk of early mortality.
(Ann Thorac Surg 2002;74:1482–7)
© 2002 by The Society of Thoracic Surgeons
series [10 –12]. The effect of subvalvular preservation
during redo MVR has not been fully assessed.
The purpose of this study was to examine outcomes
during reoperative MVR in a large contemporary cohort
of patients, with a focus on the effects of preservation of
the subvalvular apparatus on perioperative mortality.
Material and Methods
We performed a review of prospectively gathered data
on all patients undergoing MVR surgery at our institu-
tion from 1990 to 1999. Patients undergoing mitral valve
repair were excluded. We included MVR patients under-
going concomitant cardiac procedures (eg, aortic or tri-
cuspid valve surgery, coronary bypass grafting). A total
of 1,521 consecutive MVR patients were identified, of
which, 513 (34%) had undergone one or more previous
MV operations.
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Ann Thorac Surg
2002;74:1482–7
Perioperative Management for Redo MVR
A median sternotomy was performed with an oscillating
saw in nearly all patients, with a right thoracotomy
approach used rarely. Cardiopulmonary bypass (CPB)
was established via ascending aortic cannulation and
bicaval venous cannulation. Cannulation of the femoral
vessels before sternotomy was not routinely performed.
The hematocrit was maintained between 20% and 25%,
pump flow rates between 2.0 and 2.5 L/min/m2, and
mean arterial pressures between 50 and 70 mm Hg
during CPB. Myocardial protection consisted of cold
antegrade blood cardioplegia in the vast majority of
patients, with some receiving warm antegrade cardiople-
gia. Retrograde cardioplegia was used only in patients
with diseased coronary bypass grafts [13]. Mild systemic
hypothermia (30°C to 35°C) was employed during CPB in
the majority of patients, with some operations being
performed during moderate hypothermia (20°C to 29°C).
The mitral valve was approached through an incision
in the left atrium, just posterior to the interatrial groove,
in nearly all patients. A superior transeptal approach was
used only in patients with a small left atrium or difficult
surgical exposure. The decision of whether or not to
preserve the subvalvular apparatus was made intraoper-
atively and was at the discretion of the attending sur-
geon. Our method of subvalvular preservation has been
previously described in detail [14, 15], but the following is
a brief summary.
In those patients in whom a decision was made to
perform subvalvular preservation, we attempted to retain
native subvalvular tissue whenever possible. Redundant
valvular leaflet tissue was imbricated between the annu-
lus and prosthetic sewing ring, or excised if necessary. If
native leaflets and chordae were extensively scarred and
fibrosed, such as in rheumatic disease or advanced myx-
omatous disease, then they were excised and annular-
papillary continuity was restored with neochordae. Our
method of neochordae construction involved placing 4-0
polytetrafluoroethylene sutures (Gore-Tex; W.L. Gore &
Assoc; Flagstaff, AZ) through the fibrous heads of both
papillary muscles, then attaching these sutures at 2, 4, 8,
and 10 o’clock on the mitral annulus [14, 16]. The appro-
priate length of Gore-Tex suture was determined by
measuring the distance between the papillary heads and
the mitral annulus. We used this same technique (ie,
Gore-Tex neochordal construction) in patients who had
undergone removal of the subvalvular apparatus during
their first MVR operation. Pledgeted 2-0 braided sutures
were used to secure the sewing ring to the mitral annulus
in all patients, placing the pledgets on the ventricular
side of the mitral apparatus for all redo operations. In
those patients in whom neochordal construction was
performed, the Gore-Tex sutures were placed through
the ring of the mitral prosthesis and securely tied after
the prosthesis was in place. The mitral prosthesis was
routinely inspected before atrial closure to ensure that
retained subvalvular tissue did not interfere with pros-
thetic function. Transesophageal echocardiography was
BORGER ET AL 1483
SUBVALVULAR PRESERVATION IN REDO MVR
frequently employed post-CPB to assess prosthetic
function.
Mitral valve replacement was performed before aortic
or tricuspid valve procedures in patients requiring mul-
tivalvular operations. In those patients requiring con-
comitant coronary bypass grafting, distal anastomoses
were performed before MVR and proximal anastomoses
were performed last.
Statistical Analysis
Categorical data are expressed as percentages and con-
tinuous data as means ⫾ standard deviation throughout
the manuscript. SAS version 8.01 (SAS Institute, Cary,
NC) was used for all statistical analyses. Categorical data
were analyzed univariately by ␹2 or Fisher’s exact test,
and continuous data were analyzed by Student’s un-
paired t tests or Wilcoxon rank-sum tests where appro-
priate. Stepwise multivariable logistic regression analysis
was used to calculate risk-adjusted odds ratios and to
determine the independent predictors of perioperative
mortality, defined as death during the same hospitaliza-
tion. All variables suggested by the univariate analysis (p
⬍ 0.25) or those judged to be clinically important were
entered into the logistic regression model. Model dis-
crimination was evaluated by the area under the receiver
operating characteristic (ROC) curve, and model preci-
sion was evaluated by the Hosmer-Lemeshow goodness-
of-fit statistic, as previously described [17].
Results
First-Time Versus Redo MVR Patients
A total of 1,521 patients underwent MVR at our institu-
tion from 1990 to 1999, of which, 513 (34%) had one or
more previous mitral valve operations. The prevalence of
perioperative mortality was 6.9% in first-time MVR pa-
tients versus 9.0% in redo patients (p ⫽ 0.13). There were
no statistically significant differences between first-time
and redo MVR patients for ventilation time (34 ⫾ 60 vs 31
⫾ 54 hours, respectively, p ⫽ 0.30), intensive care unit
(ICU) length of stay (3.2 ⫾ 5.9 vs 3.4 ⫾ 5.8 days, p ⫽ 0.38),
or hospital length of stay (13.7 ⫾ 12.8 vs 13.9 ⫾ 10.8 days,
p ⫽ 0.77).
Table 1 displays the prevalence of risk factors in
first-time and reoperative MVR patients. The redo pop-
ulation had a significantly higher prevalence of female
gender, New York Heart Association (NYHA) class IV
symptoms, urgent or emergent timing, previous stroke or
transient ischemic attack (TIA), and atrial fibrillation. In
addition, redo MVR patients were less likely to receive
subvalvular preservation of the mitral valve, had more
concomitant aortic and tricuspid valve procedures, and
had longer CPB times. In contrast, first-time MVR pa-
tients were more likely to be older and more likely to
have left ventricular (LV) dysfunction, a preoperative
myocardial infarction (MI), unstable angina, diabetes,
and hypertension. First-time MVR patients were also
more likely to undergo concomitant coronary bypass
grafting.
1484 BORGER ET AL Ann Thorac Surg
SUBVALVULAR PRESERVATION IN REDO MVR 2002;74:1482–7

Table 1. Prevalence of Risk Factors in First-Time and

Reoperative MVR Patients
First-Time Redo
MVR MVR
Variable (n ⫽ 1,008) (n ⫽ 513) p Value

Age (years) 60 ⫾ 13 57 ⫾ 13 ⬍0.001

Female gender 556 (55%) 352 (70%) ⬍0.001
LV ejection fraction ⬍40% 201 (20%) 75 (15%) 0.01
NYHA class IV 356 (35%) 227 (44%) 0.002
CCS class IV 115 (11%) 9 (1%) ⬍0.001
Urgent timing 136 (13%) 85 (17%) 0.02
Acute endocarditis 65 (6%) 34 (7%) 0.44
Hypertension 313 (31%) 84 (17%) ⬍0.001
Recent myocardial infarction 55 (5%) 3 (1%) ⬍0.001
Renal failure 36 (4%) 19 (4%) 0.89
Diabetes mellitus 132 (13%) 48 (9%) 0.03
Fig 1. Technique of subvalvular preservation employed in redo mi-
Peripheral vascular disease 71 (7%) 23 (4%) 0.06
tral valve replacement patients. Note that proportions do not total
Hx of CVA/TIA 128 (13%) 119 (23%) ⬍0.001 100% because methods of subvalvular preservation (ie, native leaflet
Hx of atrial fibrillation 435 (43%) 315 (62%) ⬍0.001 preservation and/or Gore-Tex neochordal construction) were not mu-
MV pathology tually exclusive. (Ant ⫽ anterior; Post ⫽ posterior.)
Rheumatic 605 (60%) 211 (41%) ⬍0.001
Ischemic 149 (15%) 7 (1%)
Myxomatous 190 (19%) 24 (5%) diately preceding mitral valve procedure was a repair in
Prosthetic dysfunction 0 (0%) 240 (47%) 44% of patients and a replacement in 56%. The prosthesis
Other 64 (6%) 31 (6%) used during the reoperative procedure was mechanical
MV prosthesis size (mm) 29 ⫾ 1.9 28 ⫾ 1.7 0.03 in 82% of patients and bioprosthetic in 18%.
Subvalvular preservation 730 (72%) 225 (44%) ⬍0.001 A total of 13 surgeons performed redo MVR surgery
Concomitant procedures over the 10-year time period of this study. The percent of
AV surgery 291 (29%) 172 (33%) ⬍0.001 redo MVR patients who received some form of subval-
TV surgery 105 (10%) 138 (27%) ⬍0.001 vular preservation ranged from 4% to 60% for different
CABG 329 (33%) 57 (11%) ⬍0.001 surgeons. Figure 1 displays the method of subvalvular
CPB temperature preservation used for redo MVR patients. The subvalvu-
Normothermic 16 (1%) 0 (0%) ⬍0.001 lar apparatus was preserved (by retaining the native
Mild hypothermia 845 (84%) 393 (76%) posterior valve leaflet, retaining both valve leaflets,
Moderate hypothermia 146 (14%) 118 (23%) and/or neochordal construction with Gore-Tex) in 44% of
Deep hypothermia 1 (1%) 2 (1%) all redo MVR patients. No method of subvalvular pres-
Cold cardioplegia 940 (94%) 480 (94%) 0.68 ervation was performed in 56% of patients. As can be
Retrograde cardioplegia 154 (15%) 82 (16%) 0.18 seen in Figure 2, the proportion of patients who received
CPB time (min) 116 ⫾ 49 123 ⫾ 55 0.008 subvalvular preservation was relatively stable over the
Cross-clamp time (min) 87 ⫾ 38 88 ⫾ 38 0.79 time period of the study.
Figure 3 displays perioperative mortality according to
Continuous variables are expressed as means ⫾ standard deviation.
AV ⫽ aortic valve; CABG ⫽ coronary artery bypass graft; CCS ⫽
Canadian Cardiovascular Society angina class; CPB ⫽ cardiopulmo-
nary bypass. CVA ⫽ cerebrovascular accident (stroke); Hx ⫽
history; LV ⫽ left ventricle; MV ⫽ mitral valve; MVR ⫽ mitral
valve replacement; NYHA ⫽ New York Heart Association heart
failure class; TIA ⫽ transient ischemic attack; TV ⫽ tricuspid
valve.

Redo MVR Patients

Redo MVR was performed in 513 patients. One prior MV
operation was performed in 396 patients, two prior MV
procedures in 76 patients, three procedures in 24 pa-
tients, four procedures in 12 patients, and five procedures
in 3 patients. Perioperative mortality tended to increase
with the number of prior operations (7% for one prior
procedure, 11% for two, 29% for three, 8% for four, and Fig 2. Proportion of redo mitral valve replacement patients who re-
33% for five; p ⫽ 0.004). The average length of time ceived some form of subvalvular preservation over the time period of
between MV operations was 9.4 ⫾ 5.2 years. The imme- the study.
Ann Thorac Surg
2002;74:1482–7
Fig 3. Perioperative mortality in redo mitral valve replacement pa-
tients with and without preservation of the subvalvular apparatus.
whether or not some form of subvalvular preservation
(ie, retaining native posterior valvular tissue, retaining
native anterior and posterior tissue, or neochordal con-
struction) was performed. Mortality was significantly
lower in patients who received some form of subvalvular
preservation, but did not significantly differ between the
various types of subvalvular preservation.
A total of 46 patients (9.0%) died in hospital after redo
MVR surgery. Variables assessed as possible univariate
predictors of mortality are listed in the Appendix. Signif-
icant (p ⬍ 0.05) univariate predictors of mortality were
left ventricular dysfunction, urgent timing, acute endo-
carditis, renal failure, peripheral vascular disease, previ-
ous stroke or TIA, congestive heart failure, number of
previous MV operations, previous MV replacement (vs
repair), failure to preserve the subvalvular apparatus,
concomitant surgical procedures, and increased CPB and
aortic cross-clamp times.
Logistic regression analysis was performed to deter-
mine the risk-adjusted predictors of mortality. As can be
seen in Table 2, the independent predictors of mortality
were (in decreasing order of magnitude) failure to pre-
serve the subvalvular apparatus, prior history of stroke or
TIA, LV dysfunction, and urgent timing. Although pre-
vious mitral valve replacement (vs repair) was a signifi-
cant univariate predictor of mortality, it did not achieve
significance in the multivariable model.
Table 2. Independent Predictors of Mortality (n ⫽ 46)
During Redo Mitral Valve Replacement
Odds 95% Confidence
Variable Ratio Interval p Value
No subvalvular 3.4 1.5–7.6
preservation
Renal failure 3.2 1.0 –10.1
Previous stroke/TIA 2.5 1.3– 4.9
Left ventricular dysfunction 1.6 1.0 –2.6
Urgent timing 1.5 1.1–2.1
TIA ⫽ transient ischemic attack.
BORGER ET AL 1485
SUBVALVULAR PRESERVATION IN REDO MVR
Comment
Reoperative MVR is a common clinical entity in current
cardiac surgery. Approximately one-third of MVR pa-
tients in this large, contemporary study had one or more
previous mitral valve operations. The preceding mitral
valve procedure was a prosthetic replacement in just
over one-half of redo patients and a repair in the remain-
ing patients. The prevalence of redo MVR may be in-
creasing over time as long-term survival improves after
first-time MVR, and as the use of bioprosthetic valves
becomes increasingly common [10].
In the current study, the risk of mortality was not
significantly higher for reoperative (redo) MVR surgery
when compared with first-time MVR. It should be noted,
however, that we excluded all mitral valve repair patients
in the current study. Exclusion of these low-risk patients
resulted in a relatively high prevalence (6.9%) of opera-
tive mortality in first-time MVR patients. We feel our
operative mortality rate of 9.0% in redo patients com-
pared favorably with the 6.9% for first-time patients, as
well as with reports from other centers of mortality
during redo MVR [10 –12]. The relatively low prevalence
of mortality in redo MVR patients was particularly en-
couraging given the high-risk profile of these patients.
That is, redo MVR patients were more likely to be in
NYHA class IV heart failure and more likely to be
undergoing urgent or emergent surgery than first-time
MVR patients. In addition, redo MVR patients were more
likely to undergo multiple valvular procedures, although
concomitant coronary bypass was more prevalent in
first-time patients.
It has been well demonstrated, in both clinical and
laboratory studies, that preservation of the subvalvular
apparatus during first-time MVR is associated with im-
proved outcomes. We have previously demonstrated in
canine [18] and porcine [19] models that LV dimensions
and function post-MVR are better with subvalvular pres-
ervation than with complete excision of native valve
tissue. Similarly, the Stanford group has used large
animal models to demonstrate that preserved annular-
papillary continuity results in improved LV function [20]
and decreased LV strain [21] post-MVR when compared
with native valve excision.
Several investigators have demonstrated the beneficial
effects of subvalvular preservation on clinical outcomes
after first-time MVR. We performed a randomized trial in
16 patients undergoing MVR for chronic mitral regurgi-
tation, and found that subvalvular preservation resulted
in improved LV ejection fraction and preload recruitable
stroke work 3 months and 5 years postoperatively [1]. We
also examined a group of high-risk patients undergoing
MVR after a recent myocardial infarction [4]. We found
0.003 that failure to preserve annular-papillary continuity was
an independent predictor of early and late mortality.
0.04
Similarly, Lee and associates examined 612 consecutive
0.007
MV surgery patients and found that failure to preserve
0.05
the subvalvular apparatus was an independent predictor
0.02
of early and late mortality [9]. Wasir and associates
recently demonstrated in a prospective study that sub-
1486 BORGER ET AL
SUBVALVULAR PRESERVATION IN REDO MVR
valvular preservation is associated with improved LV
function and exercise capacity post-MVR [6]. Wu and
associates randomized 68 patients with rheumatic mitral
disease to receive subvalvular preservation or complete
excision of the native valve during MVR, and found
improved early survival and LV function in the preser-
vation group [7]. In addition to the beneficial effects of
subvalvular preservation on LV performance post-MVR,
this technique likely decreases the risk of myocardial
rupture, an uncommon but disastrous complication of
MVR [22].
Preservation of the native subvalvular apparatus can
be achieved by retaining both the anterior and posterior
leaflets, or by retaining the posterior leaflet only. There is
some evidence that preservation of both leaflets results in
better LV function post-MVR than preservation of the
posterior leaflet alone [23]. In those patients requiring
excision of native leaflets secondary to extensive fibrosis
and scarring (ie, advanced rheumatic or myxomatous
disease), preservation of annular-papillary continuity can
be performed via neochordal construction with Gore-Tex
sutures. In the current study, the results achieved with
neochordal construction were similar to those achieved
with native tissue preservation and were superior to
patients who received no subvalvular preservation. We
therefore believe that neochordal construction is the
procedure of choice in patients with advanced rheumatic
or myxomatous disease. Gore-Tex can also be used to
shorten elongated native chordae, while retaining native
valve tissue. We have previously demonstrated that neo-
chordal construction with Gore-Tex is a safe and durable
technique, with excellent function up to 10 years postop-
eratively [24]. Although Gore-Tex neochordal construc-
tion is more commonly used for mitral valve repair, it is
also eminently feasible and efficacious for MVR surgery,
particularly in patients with extensive scarring of the
subvalvular apparatus.
We have previously examined the feasibility of re-
preservation of chordae tendinae during redo MVR [16].
We analyzed 54 reoperative patients who underwent
chordal preservation/reconstruction at the time of their
first MV operation. The papillary muscles and Gore-Tex
neochordae were intact in all patients up to 22 years after
the first operation. All preserved chordae were in excel-
lent condition and freely mobile, except in 1 patient. A
preserved posterior chord was adherent to the biopros-
thetic stent in this patient, requiring careful dissection for
represervation. Operative times in patients undergoing
chordal represervation were similar to patients who did
not undergo subvalvular preservation. We concluded
that chordal represervation was safe and feasible during
redo MVR [16].
In the current study, we examined a much larger group
of reoperative MVR patients who underwent surgery
over a 10-year time period. Subvalvular preservation, by
native leaflet preservation or neochordal construction,
was performed in almost one-half of the 513 patients.
Preservation of the subvalvular apparatus was associated
with a significantly decreased risk of perioperative mor-
tality. Failure to preserve mitral annular-papillary conti-
Ann Thorac Surg
2002;74:1482–7
nuity was the biggest independent predictor of mortality.
Furthermore, it was the only risk factor identified that
cardiac surgeons are able to influence. We therefore
strongly recommend preservation of the subvalvular
apparatus during redo MVR in order to lower the risk of
mortality.
It is noteworthy that over one-half of patients in the
current study did not receive any form of subvalvular
preservation during redo MVR. There are two probable
explanations for this finding. First, the beneficial effects of
subvalvular preservation were still controversial during
the time period of the current study, particularly in the
earlier years. Second, preservation of the subvalvular
apparatus may increase operative time and complexity,
which may have caused some surgeons to avoid this
technique in redo patients. It should be restated that the
decision of whether or not to preserve the subvalvular
apparatus was at the discretion of the operating surgeon
in the current study. Some surgeons were undoubtedly
more willing to perform this procedure than others, a
finding reflected by the significant variation in preserva-
tion rates between surgeons. Therefore, some of our
results may have been “surgeon specific,” and this is one
of the main limitations of our study. However, the trend
in outcomes was consistent for all surgeons: operative
mortality was lower in patients who received preserva-
tion of the subvalvular apparatus than for those without
preservation for every surgeon. We therefore believe that
subvalvular preservation during redo MVR is feasible
and reproducible, particularly for surgeons who rou-
tinely use this technique in first-time MVR. It is now our
policy to perform preservation of the subvalvular appa-
ratus, via native leaflet preservation or Gore-Tex neo-
chordal construction, whenever possible in first-time and
redo MVR patients.
In summary, reoperative MVR can be performed with
an acceptable risk of mortality, despite the relatively
increased risk profile of redo patients. Preservation of the
subvalvular apparatus is associated with a decreased risk
of mortality during redo MVR. Although subvalvular
preservation may increase operative complexity, we
strongly recommend the use of this technique in first-
time and redo MVR surgery.
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