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Journal of the American College of Cardiology
© 2012 by the American College of Cardiology Foundation
Published by Elsevier Inc.
Vol. 60, No. 15, 2012
ISSN 0735-1097/$36.00
http://dx.doi.org/10.1016/j.jacc.2011.11.081
STATE-OF-THE-ART PAPER
Surgical Approaches to Mitral Regurgitation
Donald D. Glower, MD
Durham, North Carolina
Surgical approaches to correct mitral regurgitation (MR) have evolved over 50 years and form much of the basis
for percutaneous approaches to the mitral valve. Surgical mitral repairs have been more durable with use of annuloplasty, but recurrent regurgitation not resulting in reoperation can occur. The mitral leaflets may be resected
or augmented, with recent trends to preserve leaflet coaptation surfaces if possible. Mitral chords tend to be
replaced or transferred instead of being shortened. Mitral replacement still has a role when more durable and
reliable than repair. Surgical incisions have varied from full sternotomy down to percutaneous access only, with
less invasiveness usually requiring a trade-off versus effectiveness or ease of application. Less invasive options
in treating MR may encourage higher-risk patients to seek anatomic therapy, whether surgical or percutaneous.
Rapidly evolving technology will continue to be a dominant driver of surgical approaches to MR, with increasing
overlap and interaction with percutaneous approaches. (J Am Coll Cardiol 2012;60:1315–22) © 2012 by the
American College of Cardiology Foundation
A successful surgical approach to mitral regurgitation (MR)
was first reported as early as 1951 by Bailey et al. (1). Since
that time, surgical and percutaneous interventions to treat
MR have evolved tremendously. At present, percutaneous
means to repair the mitral valve (MV) or even replacing the
MV appears to be on the horizon and promises to dramatically alter the treatment and selection of patients with MR.
The purpose of this review is to summarize current surgical
practice in treating MR, and to suggest where treatment for
MR might be heading in the near future.
A Brief History
Bailey et al. (1) first approached MR through a left
thoracotomy, and the mitral annulus was narrowed by
external constriction of the base of the heart in an approach
not unlike recent attempts to perform mitral annuloplasty
through the coronary sinus. Lillehei et al. (2) performed the
first direct suture annuloplasty of the MV in 1957 using
cardiopulmonary bypass (CPB), and Starr and Edwards (3)
first replaced the mitral valve using a commercially successful device in 1960. Today, surgery for MR is performed in
40,000 patients each year in the United States. One should
be aware that, in this age of rapidly advancing percutaneous
technology that is used both by surgeons and nonsurgical
interventionists, the term “surgical” could, in fact, be considered an anachronism.
From the Department of Surgery, Duke University, Durham, North Carolina. Dr.
Glower has received a research grant without funding from Abbott; and research
grants from St. Jude Medical and Edwards Lifesciences.
Manuscript received July 11, 2011; revised manuscript received November 17,
2011, accepted November 22, 2011.
Anatomic Approaches to the Mitral Valve
The MV sits between the left atrium and the left ventricle, and
can therefore be approached from either of those 2 chambers.
At present, nearly all surgical access to the MV is through the
left atrium. Rarely, the MV is approached through the left
ventricle or the aortic root.
The left ventricular apex has previously been used to
perform closed mitral commissurotomy. More recently, a
transapical approach has been used to replace the MV using
a percutaneous, stented aortic valve device in a patient with
failed biological mitral prosthesis (4). Mitral chordae have
also been replaced through a transapical approach (5). A
transventricular approach to MV repair has been described
in patients having left ventriculotomy performed for left
ventricular aneurysm (6,7). The transventricular approach at
the time of ventricular aneurysm repair is best suited for
simple replacement or commissural annuloplasty.
Surgical Incisions to Access the Mitral Valve
To access the anatomic approaches to MR listed above,
several skin incisions have been used, including sternotomy,
thoracotomy, or percutaneous access. With wide use of
CPB in the 1960s, median sternotomy replaced right
thoracotomy as the primary surgical approach to treat MR
due to reliability, speed, and excellent access to most of the
heart. The skin incision for full sternotomy can be made as
small as 8 cm and can be a cosmetic inframammary incision
in women. Disadvantages to median sternotomy include
blood loss, slow sternal healing, potential for sternal nonunion, and morbidity and mortality from deep sternal
infection, which may affect 1% to 2% of cases.
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Glower
Surgical Approaches to Mitral Regurgitation
Because of patient demand,
marketing forces, and improved
technology, the percentage of
CPB ⴝ cardiopulmonary
MV operations done with minibypass
mally invasive incisions other
LV ⴝ left ventricular
than sternotomy have steadily inMV ⴝ mitral valve
creased to 20% of all mitral opMR ⴝ mitral regurgitation
erations in 2008 (8). Although
large, controlled studies are lacking, minimally invasive approaches to the MV have been
associated with faster recovery, less blood loss, and less
infection (9). Disadvantages can include increased operative
difficulty, increased procedure and pump times, limited
access to the rest of the heart, potentially more equipment
costs, and possibly more stroke due to greater use of femoral
arterial cannulation for CPB (8,10).
Partial superior sternotomy has been the most popular
minimally invasive approach to the MV since the work of
Gillinov and Cosgrove (11). Before median sternotomy,
mitral operation for regurgitation was performed through
right thoracotomy by Lillehei et al. in 1956 (2). Many series
now describe smaller right thoracotomies termed “mini”
thoracotomy or “port access” (12,13), with an incision
length somewhere between full thoracotomy (20 cm) and an
endoscopic port (0.5 cm to 1.5 cm).
Transapical access to the MV can be obtained through a
small left anterior thoracotomy and has been reported for
valve-in-valve redo mitral replacement using the Sapien
(Edwards Lifesciences, Irvine, California) percutaneous
valve device (4). Inferior partial sternotomy, right parasternal incision, and left thoracotomy have all seen limited use
due to worse exposure or more chest trauma than other
approaches.
To patients and to most surgeons, the term “totally
endoscopic” has generally implied no incision larger than
the port for a 0.5 to 1.5 cm endoscope. However, in cardiac
surgical circles, “totally endoscopic” has also been used to
describe a right minithoracotomy in the 4 cm to 8 cm range
with no rib spreading (14). To avoid confusion of terminology, Chitwood et al. (15) proposed a classification system
whereby minimally invasive approaches are categorized, as
in Table 1, on the basis of whether the surgeon uses direct
vision, thoracoscopic visualization, or robotics for any portion of the surgery. Totally endoscopic MV surgery with no
chest incision ⬎1.5 cm generally requires robotic assistance
and groin incision for femoral arterial and venous access.
Abbreviations
and Acronyms
Levels
Invasive
Mitral
Surgery*
Tableof1 Minimally
Levels of
Minimally
Invasive
Mitral Surgery*
Direct vision mini-incision (10 to 12 cm)
Video-assisted microincision (4 to 6 cm)
Video directed or robotic assisted (3 to 4 cm)
Robotic telemanipulation (1 cm)
Percutaneous
*Modified from Chitwood and Rodriguez (15).
JACC Vol. 60, No. 15, 2012
October 9, 2012:1315–22
Robotic assistance for MV surgery as currently practiced
first became available in 2000 and has been championed by
Mohr, Chitwood, and others (16). The current daVinci
robot (Intuitive Surgical, Sunnyvale, California) is a
remotely controlled servo where 1 or 2 operating surgeons
sit at a console away from the patient and manipulate 2 to
4 servo-controlled arms. The robotic arms offer scaling
where the instruments move smaller distances than the
operator’s hands, tremor reduction, stereoscopic vision,
and ⫻10 magnification. An additional bedside surgeon is
needed to load the various robotic arms, pass sutures in
and out of the wound, cut, tie, and perform manipulation
not done by the robotic arms. The greatest merit to
robotic assistance comes when surgical incisions are
sufficiently small to prevent facile operating directly
through the minithoracotomy (generally 4 cm or less)
(Table 1). Disadvantages of a robotic approach include
equipment cost and complexity, size and bulk of current
technology, and difficulty with knot tying.
Percutaneous Access to the Mitral Valve
The only well-documented percutaneous approach to MR
in the United States today is the MitraClip (Abbott
Laboratories, Abbott Park, Illinois), which remains in trial
in the United States (17). This is a 13-mm clip that is
applied to attach the anterior and posterior mitral leaflets
together, similar to the surgical edge-to-edge surgical repair
technique (see following discussion). The MitraClip is
placed from the femoral vein and through the interatrial
septum.
Initial results of the North American EVEREST (Efficacy of Vasopressin Antagonism in Heart Failure: Outcome
Study With Tolvaptan) trial and the European experience
show that MitraClip can reduce MR, reduce left ventricular
volume, and improve quality of life and heart failure
symptoms at 1 to 2 years (17). Limitations of the MitraClip
include the requirement of a localized regurgitant jet,
technical challenges of the transseptal approach, and lack of
results beyond 2 to 3 years.
Concern has been voiced that MitraClip placement
without ring annuloplasty may duplicate surgical reports of
higher recurrent MR due to lack of an annuloplasty ring
(11). Conversely, Maisano et al. (18) reported a series of
patients with surgical edge-to-edge repair without ring with
freedom from reoperation or ⬎2⫹ MR of 80% at 12 years.
Many of these patients had annular calcification, which may
have effectively served as an annuloplasty.
An additional concern voiced is that MitraClip placement may increase the likelihood of needing subsequent
replacement instead of repair. This concern is supported by
data from the EVEREST trial and from Germany, where
replacement rates were higher than expected in patients
requiring surgery after MitraClip placement (19,20). Nonetheless, more data will be needed, as these are small series
with short term follow-up and a relatively inexperienced
JACC Vol. 60, No. 15, 2012
October 9, 2012:1315–22
surgical community regarding repair of valves with a
MitraClip in place (21). Most would interpret available data
as supporting the MitraClip in patients who are high risk
for surgery and have limited life expectancy (22).
Mitral Repair Techniques
Annuloplasty. Direct vision mitral annuloplasty was reported by Lillehei et al. in 1958 (2). Many studies have
shown that mitral repairs employing some form of ring
mitral annuloplasty have better durability than do ringless
repairs (Fig. 1A) (23). This observation may result from the
fact that nearly all valves with significant chronic MR have
some degree of annular dilation. In addition, unlike normal
hearts, failing hearts have permanent plasticity where the
heart forever continues to deform favorably or unfavorably
under changing loading conditions. That is not to say that
all ringless repairs fail (24), only that recurrent MR is more
likely if annuloplasty is not performed.
Mitral annuloplasty can be categorized as complete or
partial annuloplasty, as suture annuloplasty versus ring
annuloplasty, and as rigid versus flexible ring annuloplasty.
Partial annuloplasty and suture annuloplasty may be useful
in children because of the potential for the unsutured
annulus to grow and avoid mitral stenosis. For myxomatous
MVs with prolapse, both rigid and flexible rings have
similarly good results. Flexible rings theoretically have the
advantage of allowing the base of the heart to contract,
whereas rigid rings are more resistant to central leakage in
patients with left ventricular (LV) dilation. In patients with
functional MR, the net advantages of the complete rigid
ring exceed those of the flexible ring (25). One series of
prolapse patients suggests that flexible rings may have less
ring dehiscence than rigid rings (26). Rigid rings may give
more predictable geometry after repair for lower volume
surgeons. The relative role for different ring shapes is
Figure 1
Glower
Surgical Approaches to Mitral Regurgitation
1317
unclear, except that narrowing the septal-free wall diameter
is important in functional regurgitation (27). Concern has
been expressed that smaller under-sized (24 mm or 26 mm)
mitral rings could cause mitral stenosis and/or LV diastolic
dysfunction (28). However, most agree that a 4 to 6 mm Hg
mean gradient across a 24 to 26 mm ring is of less
physiologic importance than is recurrent MR. Large series
suggest that both partial and complete rings can provide
good results in myxomatous prolapse valves. Complete,
rigid rings, again, are considered by most surgeons to have
the best results in patients with functional MR (25).
Leaflet resection. In addition to the ring annuloplasty,
Carpentier et al. (29) made the major contribution of
suggesting quadrangular resection of redundant posterior
leaflet segments (Fig. 1B). By undermining the remaining
posterior leaflet segments, more than one-half of the posterior leaflet can be resected. This “sliding leaflet plasty”
reduces the height (annulus to free edge) of the remaining
posterior leaflet to ⬍1.5 cm to prevent anterior leaflet
systolic anterior motion. A small triangular resection may be
used for smaller segments of the posterior leaflet. Although
posterior leaflet resection has been shown to be very
reproducible, concern has surfaced that, in some patients,
resectional techniques can decrease coaptation between the
remaining posterior and anterior leaflets with subsequent
recurrent regurgitation due to further valve remodeling (26).
Equilateral triangular resections of the anterior leaflet up to
approximately 1 cm in length can be used to correct focal
anterior leaflet pathology (29).
Chordal replacement, shortening. Ruptured, elongated,
or shortened primary chords can be replaced without leaflet
resection. Normal chords can be transferred from secondary
chords on the same leaflet or from primary chords on the
opposing posterior leaflet (Fig. 1C). Increasingly, surgeons
have been replacing chords with polytetrafluoroethylene
Common Established Surgical Techniques Used to Correct Mitral Regurgitation
(A) Ring annuloplasty. (B) Quadrangular resection and sliding leaflet plasty. (C) Chordal transfer. (D) Cleft closure. (E) Mitral replacement. Figure illustration by Craig Skaggs.
1318
Figure 2
Glower
Surgical Approaches to Mitral Regurgitation
JACC Vol. 60, No. 15, 2012
October 9, 2012:1315–22
Newer Surgical Techniques Used to Repair Regurgitant Mitral Valve
(A) chordal replacement. (B) Posterior leaflet augmentation. (C) Edge-to-edge Alfieri stitch (valve shown in diastole with double orifice).
(D) Papillary muscle approximation. (E) Posterior wall reduction. Figure illustration by Craig Skaggs.
suture (Fig. 2A) (30,31). Disadvantages of chordal replacement remain difficulty getting chordal length right and
stable chordal attachment to the mitral leaflet and papillary
muscle.
Leaflet augmentation or patch. Leaflet perforations have
long been patched using fixed native or bovine pericardium.
Recently, restricted posterior leaflets have been patch augmented with some early success (Fig. 2B) (32). Long-term
results of leaflet patching are unclear in any situation.
Cleft closure. Large leaflet clefts can occur with congenital
leaflet variants and are easily closed (Fig. 1D). Many
regurgitant MVs of any etiology can have abnormally open
clefts due to annular dilation. These also can be sutured
closed to improve the repair.
Edge-to-edge repair. Alfieri et al. (33) described a technique first applied in 1992 in which leaflet malapposition
was corrected by suturing the anterior leaflet to the
posterior leaflet in 1 place (Fig. 2C). The name “edgeto-edge” is a bit of a misnomer because ideally 3 mm to
5 mm of each leaflet edge is opposed to the other leaflet
to force an area with a coaptation height of at least 3 mm
to 5 mm. The edge-to-edge repair also can prevent
systolic anterior motion of the anterior leaflet with LV
outflow tract obstruction by fixing the anterior leaflet to
the posterior leaflet (34). The edge-to-edge technique is
generally used in conjunction with annuloplasty, but
annuloplasty may be omitted in patients with hypertrophic obstructive cardiomyopathy to minimize outflow
tract obstruction (24). Edge-to-edge repair may not be
advisable in patients with rheumatic or stiffened leaflets
or in patients with ring size ⬍30 mm to avoid significant
mitral stenosis. Limited results up to 10 years have been
published with edge-to-edge repairs (24).
Ventricular repairs. Functional MR results from LV
dilation. As a result, many authors have attempted
ventricular or papillary muscle based repairs for functional MR along with mitral annuloplasty. Posterior wall
plication (Fig. 2E) (35) and papillary muscle approximation (Fig. 2D) (36) have both been reported to have good
early results.
Results of Mitral Repair
Many factors can diminish the likelihood of mitral repair
versus mitral replacement. Factors predicting replacement
instead of repair include low surgeon/institution volume,
anterior leaflet pathology or bileaflet pathology, rheumatic
etiology, infectious etiology, functional/ischemic etiology,
and secondary leaflet changes such as scarring and/or
calcification (37). Although surgeons are under pressure to
have high rates of MV repair, recurrent MR can often be
worse than the consequences of initial mitral replacement.
“Good” repairs are generally better than replacement, but
replacement is generally better than “bad” repair with
recurrent regurgitation.
Freedom from reoperation at 20 to 25 years has been 90%
in several large series (38 – 42) (Fig. 3). Factors such as
anterior leaflet pathology or bileaflet pathology, rheumatic
etiology, infectious etiology, functional/ischemic etiology,
secondary leaflet changes such as scarring and/or calcification, lack of ring annuloplasty, and low volume for the
surgeon or institution tend to predict a higher likelihood of
reoperation (43).
Only recently have several large studies with a high degree of
echocardiography follow-up reported residual/recurrent MR after
mitral repair (26,40,42,44,45). The goal of surgical mitral repair
has been to leave the operating room with no more than
Glower
Surgical Approaches to Mitral Regurgitation
JACC Vol. 60, No. 15, 2012
October 9, 2012:1315–22
Figure 3
Freedom From Reoperation After Mitral Valve Repair
Data from Lawrie et al. (blue line) (26), Braunberger et al. (yellow line) (39),
Salvador et al. (purple line) (40), David et al. (red line) (41), and Flameng et al.
(green line) (42).
mild residual MR by transesophageal echocardiography
under anesthesia, as more than that has been associated with
a higher rate of reoperation (46). At 10 years, MR has been
reported as at least moderate in 15% to 30% of patients
having myxomatous valve repaired and severe in 5% to 10%
(Fig. 4) (26,40,42,44,45).
For patients with functional or ischemic etiology, moderate or more regurgitation has been reported in 20% to 30%
of patients at 1 to 5 years (44), prompting some surgeons to
consider mitral replacement or not addressing the MV in
some patients (47). Others have criticized these studies
because of their use of full-sized, partial, flexible rings,
which many now think allow more unfavorable annular
remodeling (48). Use of complete, rigid, and under-sized or
reduced septal-free wall diameter rings is now favored for
repair of ischemic or functional MR by many authors (48).
1319
the inherent issues of anticoagulation versus limited biological durability.
Mitral replacement does have some inherent advantages
over repair. The elimination of MR is more certain with
replacement, especially when the quality of repair is in
question. Elderly patients with limited life expectancy may
have little issue with anticoagulation therapy or limited
durability using modern bioprostheses. Mechanical mitral
replacement with anterior leaflet resection was described by
Krajcer et al. (51) for hypertrophic obstructive cardiomyopathy with effective elimination of both MR and LV outflow
tract obstruction. Some researchers believe that MV replacement may be a more effective therapy than mitral
repair for patients with ischemic MR, especially if the
mitral leaflet is restricted ⬎1 cm below the plane of the
mitral annulus (52).
The selection of biological versus mechanical prostheses
for mitral replacement remains controversial. The last decade has seen a significant shift toward biological mitral
prostheses due to an aging population, hope that reoperation can be less invasive or percutaneous, patient dislike
of anticoagulation therapy, and belief that modern bioprostheses are more durable. Unfortunately, replacement
of a failed biological prosthesis remains a morbid procedure, and a significant percentage of patients having
biological mitral replacement will require anticoagulation
therapy for atrial fibrillation during their subsequent
course. Data actually suggest that the durability of
current bioprostheses in the mitral position remain limited, especially in patients ⬍60 years of age (Fig. 5)
(53,54). Transapical replacement of failed biological
mitral prostheses has been reported using percutaneous
bioprostheses designed for the aortic position (4). Several
new anticoagulants are on the horizon with the potential
Mitral Replacement
Mitral replacement had long been the standard surgical
treatment for MR (Fig. 1E), but mitral repair is now favored
over replacement in most patients. Advantages of mitral
repair versus replacement include avoidance of mandatory
anticoagulation, potentially better durability than bioprostheses, less impairment of LV function, less risk of LV
posterior wall rupture (ventricular-annular disruption), and
lower early and late mortality (49). Some of the advantages
of mitral repair over replacement come from the fact that
previous mitral replacements tended to resect all of the
native MV chords. However, many studies have now shown
that mitral replacement with chordal preservation nearly
eliminates the risk of ventricular-annular disruption and
minimizes impairment of LV function (50). Indeed, to date,
no definitive data exist to say that mitral repair has an
advantage over chordal sparing mitral replacement, beyond
Figure 4
Freedom From Mitral Regurgitation After
Mitral Valve Repair for DMR Versus IMR
Freedom from ⬎2⫹ (red lines) or ⬎3⫹ (blue lines) mitral regurgitation after
mitral valve repair for degenerative mitral regurgitation (DMR) versus ischemic
mitral regurgitation (IMR) (26,40,42,44,45).
1320
Glower
Surgical Approaches to Mitral Regurgitation
JACC Vol. 60, No. 15, 2012
October 9, 2012:1315–22
tion. Concurrent Maze procedure may have a role in
minimizing but not eliminating atrial fibrillation in patients
at high risk for atrial fibrillation.
The Future
Figure 5
Freedom From Structural Valve
Deterioration or Reoperation
Freedom from structural valve deterioration or reoperation after biological mitral
valve replacement (53,54).
to eliminate frequent testing and/or minimize bleeding
complications with mechanical prostheses.
Indications for Mitral Repair or Replacement
As the results of surgery for MR have improved, the
threshold for operating on MR has been lowered. Today,
the mortality for isolated mitral repair is 1% to 2%, and the
mortality for isolated mitral replacement is 6% (37). Published guidelines for management of valvular heart disease
(55) are data driven and useful, but guidelines need to be
adjusted for each individual patient. For patients with a 90%
likelihood of obtaining a mitral repair, surgery today is
seldom performed as an isolated procedure for less than
severe MR because of the low mortality and the low rate of
symptoms for moderate MR.
The indications for operation on ischemic or functional
MR remain more controversial than those for degenerative
disease. Despite data that functional regurgitation is associated with impaired survival, nonrandomized studies have
suggested that survival is not improved by mitral repair for
functional regurgitation when the ejection fraction is ⬍30%
(56). Most believe that heart failure symptoms can be
improved after repair of functional regurgitation in patients
with appropriate LV functional reserve (56).
Post-Operative Management
Two controversies in the early management of surgical
patients are management of anticoagulation therapy and
atrial fibrillation prophylaxis. Unless significant atrial fibrillation occurs in the postoperative period, most mitral repair
or biological replacement patients can be managed with
aspirin alone. Short-term anticoagulation therapy with warfarin for 3 months is not uncommon, as mitral patients have
a 30% to 70% incidence of new atrial fibrillation after mitral
surgery. Most large centers would use an antiarrhythmic like
amiodarone in patients for 1 to 3 months to minimize
postoperative atrial fibrillation and subsequent anticoagula-
The next 10 years will see many changes in the surgical
approach to MR. Certainly, the very early experience with
percutaneous MV repair will grow. The percutaneous
MitraClip is a perfect example of how familiarity with
long-standing surgical approaches like edge-to-edge repair
can lead to new approaches for the interventional cardiologist. Noninterventional cardiologists need to be familiar
with the changing options and indications for evolving
surgical approaches to MR. Open surgical approaches to
MR will become less morbid as facilitating technology
develops and allows smaller incisions and/or elimination
of CPB. Stand-alone percutaneous therapies for MR will
always have the potential to be applied through open
surgical approaches also, thus blurring the distinction
between the interventional cardiologist and the cardiovascular surgeon. Collaboration between the interventional cardiologist with percutaneous skills and the cardiovascular surgeon with open skills will create hybrid
approaches to MR that would not be possible by purely
percutaneous or open procedures alone (57).
Perspective
Already today and increasingly in the future, the surgical
and interventional approaches to MR will be composed of a
spectrum of approaches, spanning from maximally invasive
to percutaneous. Patient selection for the appropriate approach will, therefore, become increasingly important once
we have data regarding the outcomes of each approach in
different patient subsets. To further complicate decision
making, procedure invasiveness/morbidity may often be
inversely related to procedure effectiveness. Thus, we may
tend to favor less invasive but less effective approaches to
treating MR in patients who are at higher risk and with
limited life expectancy. Younger- and lower-risk patients
may be more appropriate for more effective therapies while
better tolerating any morbidity or risk. As less invasive
approaches to MR become more available, some of the large
pool of patients receiving little or no therapy for MR may
become more likely to refer themselves, or to be referred, for
some form of anatomic rather than medical treatment of
their MR. Thus, technology continues to be a dominant
driver of medical care for MR, just like most other diseases.
Reprint requests and correspondence: Dr. Donald D. Glower,
Duke University Medical Center, Box 3851, Durham, North
Carolina 27710. E-mail: [email protected].
JACC Vol. 60, No. 15, 2012
October 9, 2012:1315–22
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Key Words: mitral repair y mitral surgery y mitral valve.