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P2 prolapse is the most common cause of degenerative mitral regurgitation. In the era of respect rather than resect, most of these cases are repaired with neochorda and folding of the tall P2 segment. When the enlarged P2 is thickened and calcified, a limited triangular excision is necessary for proper repair.
This video presents a repair of a mitral valve in a 73-year-old man with history of PND and one episode of pulmonary edema. The patient suffered from severe eccentric mitral regurgitation due to ruptured chordae and a thickened enlarged P2 segment.
Tips
- To attain the best result, the triangular excision should be as minimal as possible. The lines of excision should be made close to the two normal chordae on either side of the prolapsed segment.
- If the two normal chordae on either side of the prolapsed segment are too far away, the limits of the excision must be narrowed and a neochorda should be inserted at the site of repair.
- The apex of the “V” of the excision should fall short of the annulus.
- The annuloplasty stitch at the base of the P2 should be taken under vision after excision, but before approximation. The surgeon must take care not to include any basal chorda in the stitch.
- The approximation of the edges must be done with knots on the ventricular side, especially in the luminal half, to prevent the sharp ends of the prolene from damaging the anterior leaflet during apposition.
- Only the deep scallops (which are the sites of regurgitation) on either side of the repair should be closed with a stitch.
- Full ring annuloplasty is preferred.
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4 Comments
Congratulations. Very nice final result.
What kind of ring did you use?
Best regards
Ovidio
It is a Medtronic CG Future Ring- a semi rigid complete ring. Thanks
Very nice video. Normally in repair procedure, the AML is sized to select the ring as the closure of Mitral valve, in general,based on AML. But in this CG medtronic ring you measured Inter Triangular distance and chosen the valve. As the Inter triangular distance is less than Inter commissural distance, Is there any possibility of producing stenosis. Thank you sir.
Thanks Dr Arni, sharing us your how-know.
It was fair to recall your expertise in placing the annuloplasty sutures. Why did you severe the basal chorda? I think that we can limit the V resection back to the basal segment of the posterior leaflet as rarely the pathological process affect the basal segment of the leaflet that is erronously described by echocardiogram as atrio-vantricular disjunction. As far we can save basal chorda we should offer better stability and avoid annular plication stitches.
Cordially