Introduction

The concept of repairing a diseased mitral valve dates back to 1902, when Scottish physician Sir Lauder Brunton first proposed that surgical commissurotomy may benefit patients with debilitating mitral stenosis.[1] It was not until 1923, however, that Elliott Cutler performed the first mitral valve repair surgery, a transventricular mitral commissurotomy, for a bed-bound 12-year-old girl with critical rheumatic mitral stenosis.[2] The patient recovered and was discharged from the hospital several days after the historic operation. Although subsequent attempts by Cutler and others nearly all resulted in early death after surgery, the groundwork was set for mitral commissurotomy to develop as a valuable treatment option for well-selected patients with severe mitral stenosis by 1950.[3],[4]

By the early 1950s, pioneering surgeons had also begun to develop surgical repair techniques for treating mitral regurgitation.[5],[6] One technique, which involved “cinching” a dilated mitral annulus using an externally placed purse-string suture,[6] was originally derived from experimental methods used to generate large animal models of mitral stenosis for testing commissurotomy operations.[7] Following the arrival of cardiopulmonary bypass technology, C. Walton Lillehei performed the first suture annuloplasty repair of a regurgitant mitral valve under direct vision in 1957,[8] and key innovations and optimizations in repair technique were developed over the following decades by McGoon,[9] Kay,[10] Duran,[11] Carpentier,[12],[13] and many others. Today, mitral valve repair has evolved to become the ideal treatment for most etiologies of severe mitral regurgitation.

In this chapter, we review the anatomy and pathophysiology of the mitral valve, examine the current indications and outcomes for mitral valve repair, and finally illustrate the various repair techniques commonly used in reconstructive mitral valve surgery today. Of note, a dedicated discussion of mitral valve pathophysiology is presented in Chapter “Pathophysiology of the Mitral Valve” while minimally invasive and transcatheter mitral valve repair are the focus of Chapters “Minimally Invasive Mitral Valve Repair” and “Transcatheter Aortic Valve Replacement”, respectively. Finally, mitral valve surgery for patients with congestive heart failure is discussed in Chapter "Mitral Valve Repair for Congestive Heart Failure".