A report on the successful sparing of the entire anterior mitral leaflet through the implementation of a customized procedure in the context of mitral valve replacement

Mitral valve replacement (MVR) in patients with complex mitral valve (MV) pathology often necessitates excision of the anterior mitral leaflet (AML), potentially compromising left ventricular (LV) geometry and function. We describe a customised full chordal-sparing mitral valve replacement (FCS-MVRpl) technique that preserves the AML and subvalvular apparatus, aiming to maintain LV architecture and improve postoperative outcomes in patients unsuitable for MV repair. Between 2014 and 2023, 161 consecutive patients underwent FCS-MVRpl. MV pathology included degenerative (n = 94, 57.1%), functional (n = 58, 36.0%), infective (n = 9, 5.6%), and rheumatic (n = 2, 1.2%) disease. Among these, 93 patients (57.8%) exhibited complex MV pathology: massive annular calcification (n = 59, 36.6%), mitral annular disjunction (MAD; n = 25, 15.5%), and posterior annular abscesses due to endocarditis (n = 9, 5.6%). The AML was fully mobilised and translocated, preserving the entire chordal apparatus. In cases with excess leaflet tissue, partial excision of the free edge was performed to facilitate prosthesis seating while maintaining chordal integrity. At 12 months, freedom from procedural complications was 98.6% ± 0.97%, with only two adverse events (1.2%) directly attributable to the technique. Freedom from heart failure-related rehospitalisation was 94.2% ± 1.9%. Multivariable Cox regression identified reduced preoperative left ventricular ejection fraction (LVEF) as a predictor of treatment failure (HR: 0.95; 95% CI: 0.92–0.99; p = 0.015). NYHA functional class improved in the majority of patients: 112 (81.2%) were classified as Class I at follow-up, while 11 (8.0%) experienced deterioration. FCS-MVRpl is a safe and effective alternative for patients with complex MV pathology who are not candidates for repair. Preservation of the AML and subvalvular apparatus supports LV geometry and functional recovery. The technique is particularly beneficial in cases of posterior annular calcification, Barlow disease with excess leaflet tissue, and infective endocarditis involving the posterior annulus. However, it is contraindicated in cases of circumferential MV calcification. Further prospective studies are warranted to validate long-term outcomes and broader applicability.