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This video demonstrates the repair of a mitral valve with Barlow’s disease without resecting the tissue of the prolapsing leaflet. The patient was a 44-year-old man who was totally asymptomatic in sinus rhythm with no treatment, and the echocardiographic findings consisted in a preserved left ventricle ejection fraction with a 40 mm left ventricle end-systolic diameter and grade 4+ mitral regurgitation, due to a prolapse of the posterior leaflet.
Echocardiography showed features typical of Barlow´s disease: excessive myxomatous tissue, annular dilatation, leaflet thickening, bileaflet prolapse, and chordal lengthening. Valve analysis revealed a tall P2 segment of the posterior leaflet. There was no ruptured chord but the posterior segments were very elongated, and a clef between the P2 and P3 segments can be appreciated in the video. There was a large anterior leaflet, involving A2 with a lot of excess tissue. The P1 segment was of normal height. The operative technique consisted of repairing the valve without resecting the excess tissue, using Gore-Tex® neochords to create a new posterior leaflet free-edge by bending the excess tissue into the ventricular side.
After the 4/0 Gore-Tex® suture was passed through the papillary muscle, it was first attached to the margin of P2 and then continued through the body of the leaflet until reaching the middle part, as shown, leaving about 15 mm of the leaflet free up to the annulus. This procedure was repeated along the prolapsing scallop. Doing this avoids the posterior leaflet pushing the anterior one and causing systolic anterior motion. After the repair was completed, a symmetric closure line was observed between the two leaflets. The author marked it with ink, and afterwards confirmed that the surface of coaptation was adequate. This technique is totally reversible in case of failure, and there is no need to resect any scallop. As a result, there is no gap suture and no need to plicate the annulus. The patient’s postoperative echocardiography confirmed adequate height of coaptation with trivial residual regurgitation.
In conclusion, this is a nonresecting repair that is performed by bending the prolapsing segment towards the ventricle, using a technique that avoids the posterior scallop pushing the anterior leaflet and causing systolic anterior motion.
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3 Comments
Very Reproducible technique with minimal need for training in cases of Barlow’s Syndrome. Commendable effort.
Smart and simple, Jorge.
Good job, indeed.
I would like to congratulate Dr. Rodríguez-Roda for this nice video presentation. The basic principle of his technique (The Bending Plasty) is similar to our technique (The Folding Leaflet).
In our technique, the two arms of each neochordae are passed through the free margin of the prolapsing leaflet in two or three full-thickness bites. Weaving this suture from the free edge and surpassing the coaptation line produces a free-edge remodelling, resulting in a “hockey-stick” effect on the leaflet, enlarging the surface of coaptation.
In the Folding Leaflet technique, the neochordal attachment to the leaflet aims to fix the PTFE suture and remodel the leaflet, creating a large surface of coaptation. In the case of excess of tissue, the chord is repeatedly woven along the surface of coaptation, reducing the atrial surface of the leaflet to the correct level. Basically, the excess of leaflet tissue is moved from the atrial surface to the coaptation surface. In our experience, the need of leaflet resection has been completely abolished even in the case of large excess of tissue.
The level of the annulus is used to establish the correct length during the knot tying of the neochord, while the leaflet is folded towards the annulus. This can simplify the procedure in case of complex repairs with the use of multiple artificial chordae.
I would like to give our readers some references about our technique in order to clarify the most important tips for this type of MV neochordal repair.
1. Our technique has been previously published in CTSNet: The Cardiothoracic Surgery Network: two video presentations:
-A new concept for extensive use of neochordae: The Folding Leaflet. Video presentation. March 7, 2012. TOP CONTENT VIEWED DURING 2012 CTSNet: The Cardiothoracic Surgery Network. CTSNet.org. (http://ctsnet.org/article/new-concept-extensive-use-neochordae-folding leaflet).
-The Folding Leaflet Technique for Neochordal Repair in Barlow´s Syndrome: Step-by-Step. Video presentation. July 30, 2014. (http://ctsnet.org/article/folding-leaflet-technique-neochordal-repair-barlow%C2%B4s-syndrome-step-step)
2. Our original paper was published in The Annals of Thoracic Surgery:
Rafael García Fuster; Oscar Gil; Alejandro Vazquez; Aritz García; Juan Martínez León. The Folding Leaflet: A Simple Method for Neochordal Repair. Ann Thorac Surg 2010; 89: 1682-1684
-It was also published in Interact Cardiovasc Thorac Surg. 2014;18:586-95. doi: 10.1093/icvts/ivu013. Epub 2014 Feb 12.
García Fuster R, Martín E, Paredes F, Mena A, Cánovas S, Gil O, Hornero F, Martínez J. Artificial chordae in the setting of complex mitral valve repair: early outcomes using the folding leaflet technique.
3. It was presented in national and international meetings. Some of the most important meetings were:
– Rafael García Fuster. Folding Leaflet: a novel concept for facilitating neochordal repair. 2011 Mitral Conclave. New York.
-Rafael García Fuster. New concept for extensive neochordal repair without resection in Barlows Syndrome: the Folding Leaflet. 2013 Mitral Conclave. New York.
-Rafael García Fuster; Elio Martín; Federico Paredes; Armando Mena; Sergio Cánovas; Oscar Gil; Fernando Hornero; Juan Martínez León. Artificial chordae in the setting of complex mitral valve repair: early outcomes using the Folding Leaflet technique. 27th Annual Meeting of the European Association for Cardio-Thoracic Surgery. Viena, Austria 2013.
-Rafael García Fuster; Rafael Payá Serrano; Riccardo D´Ascoli; Federico Paredes; Armando Mena; Marina Juez; Oscar Gil Albarova; Fernando Hornero Sos; Juan Martínez León. Reparación mitral con empleo de múltiples neocuerdas según la técnica “Folding Leaflet”: estudio con ecocardiografía tridimensional. 2014 AATS Mitral Conclave. Curso Nacional de Patología Mitral. Madrid, España.
-Best Original Work on Mitral Valve Repair Award (Edwards Lifesciences). Rafael García Fuster; Federico Paredes; Aritz García; Elio Martín; Sergio Cánovas; Oscar Gil; Fernando Hornero; Juan Martínez León. Reparación valvular mitral con cuerdas artificiales. Qué aporta respecto a la técnica clásica. XXI Congreso de la Sociedad Española de Cirugía Torácica-CardioVascular. 2012. Published in: Cirugía Cardiovascular (Elsevier) 2013; 20: 130-138.
-Best Surgical Video Award. García Fuster R, Paredes F, Martín E. Reparación mitral con empleo extensivo de neocuerdas sin resección en el síndrome de Barlow: un nuevo concepto. XVI Congreso de la Sociedad Catalana de Cirugía Cardíaca. Barcelona 2013.
4. Our technique was also the main subject of the thesis: Folding Leaflet Technique: impianto di corde artificiali per plastiche mitraliche complesse, un nuovo metodo per semplificare la misurazione. Riccardo DAscoli. University: Sapienza. Rome 2014.
5. Folding Leaflet Technique for Neochordal Mitral Valve Repair by Dr Petar Vukicevic. https://www.youtube.com/watch?v=14goW7clfEU
Thank you for this new contribution to neochordae MV repair.