Butterfly Resection for Prolapsed Posterior Mitral Valve Leaflets

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This video demonstrates a tailored reparative strategy for a 58-year-old male who presented with severe symptomatic mitral regurgitation due to a flail posterior leaflet with marked myxomatous degeneration. Preoperative transesophageal echocardiogram (TOE) revealed excessive posterior leaflet height (>24 mm) and a single intact native chord attached to the middle of P2. 

Following exposure through Sondergaard’s groove, two flail segments were identified on either side of the preserved native chord. The objective of the repair was to reduce both leaflet height and width while maintaining chordal integrity and restoring a symmetrical coaptation surface. Given the excessive height and asymmetric pathology, two separate butterfly resections were performed, each tailored to the local leaflet morphology. Reconstruction after each resection was completed using 5-0 Prolene sutures, with careful attention taken to avoid over-resection. 
 
Annuloplasty sutures were then placed, and the anterior leaflet height was used to select an appropriately sized mitral valve annuloplasty. Exposure of the papillary muscles allowed for the implantation of two pairs of Gore-Tex neochordae to support the resected segments. Their lengths were adjusted to match the height of the adjacent native chords to ensure anatomical coaptation alignment. Following ring implantation and final adjustment of the neochordae height, repeat water testing demonstrated excellent competence. Ink testing confirmed a coaptation height exceeding 8 mm, and immediate postoperative TOE showed complete resolution of mitral regurgitation with no evidence of systolic anterior motion. 
 
This case highlights the importance of intraoperative anatomical assessment in degenerative posterior leaflet disease. The presence of a single central native chord necessitated a dual-resection approach, enabling preservation of the subvalvular apparatus while achieving uniform leaflet height and optimal coaptation geometry. The resulting repair demonstrates a reproducible method for managing tall, flail posterior leaflets where excessive tissue height and asymmetry may otherwise compromise durability or predispose to postoperative systolic anterior motion (SAM). 

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