Cardiac valve surgery- the "French correction". J Thorac Cardiovasc Surg 1983; 86:323-337
Prior to the invention of cardiopulmonary bypass, a few attempts were made to correct mitral regurgitation by pericardial approaches. They were almost always unsuccessful and abandoned. After the advent of cardiopulmonary bypass, several repair techniques were described to correct pure mitral regurgitation. Walton Lillehei performed the first mitral valve repair under direct vision by suture plication of both commissural areas in 1956. The principle concept behind these repair procedures was the over-narrowing of the mitral orifice to reduce the size of the annulus and to correct valvular regurgitation. These palliative techniques were progressively abandoned for three main reasons: first, they failed to produce a reliable and predictable result, second they were associated with a high rate of early recurrent mitral regurgitation or induced mitral stenosis, and third, suitable valvular prostheses became available.
In the late 1960's, several clinical studies demonstrated that prosthetic valve replacement in the mitral position was associated with serious drawbacks. Structural valve degeneration was the most common complication of the biological valves requiring a second operation whereas anticoagulation-related events were a major source of morbi-mortality in patients with mechanical valves. Carpentier was convinced that in the mitral position, surgical techniques preserving the native valve were superior to valve replacement. He was also aware of the conceptual limitations of repair techniques available at that time. As previously mentioned, these palliative procedures were commonly complicated with recurrent mitral regurgitation or stenosis as a result of dysfunctions of the leaflets, the persistent process of annular dilatation, and the fibrous transformation of the plicated commissure. In 1968, Carpentier introduced the concept of remodeling annuloplasty using a prosthetic ring and opened a new era in mitral valve reconstructive surgery.
The principle goals of the remodeling annuloplasty were to restore the normal shape and size of the annulus while respecting the normal motion of the leaflets and the commissures. The prosthetic ring would also stabilize the mitral annulus in the systolic position and prevent its further dilatation.
The introduction of remodeling annuloplasty allowed the development of complementary reconstructive techniques. In the early 1970's, Carpentier and his team performed extensive anatomic studies of the mitral valve in both normal and pathologic conditions to identify precisely all valvular lesions enabling them to design appropriate reconstructive techniques.
In the late 1970's the anatomic approach, "too complex to be practical", was abandoned and more attention was placed on the valve dysfunction resulting from these anatomic lesions.
The functional approach, first described in 1978, was based on the analysis of the motion of the leaflets during diastole and systole. Three functional types were distinguished depending upon whether the leaflet motion is normal (type I) increased (type II) or decreased (type III).
In his landmark paper, The "French correction," published in 1983, Carpentier wrote:
"Surgeons are not basically concerned with lesions. We care more about function. Therefore one may define the aim of a valve reconstruction as restoring normal valve function rather than normal valve anatomy. This functional approach has led to a significant simplification. There are only two functional anomalies: The opening and closing motions of each leaflet are either increased as with leaflet prolapse or diminished as with restricted leaflet motion."
Nowadays, the functional classification has become the foundation of valve analysis and reconstruction. Preoperatively, the functional classification allows the echocardiographer to assess and localize valvular dysfunctions. It provides valuable information to the surgeon, who can then proceed intraoperatively to a complete inventory of the lesions in the areas where a dysfunction has been identified. The exact determination of the valvular dysfunctions and lesions allows the surgeon to design the appropriate reconstructive procedure(s) based on the "one-lesion-one-technique" principle.
Following the pioneering work of Alain Carpentier, several groups in Europe, North America and Asia implemented successfully his reconstructive techniques into their practices. Today, Carpentier's reconstructive valve surgery is the gold standard in the management of patients with mitral valve disease. The procedure is extremely safe, reliable, and reproducible with excellent early and late results. As Carpentier has remarked: "For the first time in the history of valvular disease, patients can be cured for the rest of their lives."