Mitral Valve Repair Using the Sandwich Technique for Symmetrical Bileaflet Prolapse

This video demonstrates a simplified ring-only mitral valve repair technique for patients with symmetrical bileaflet mitral valve prolapse, annular dilatation, and centrally directed multiple jets of mitral regurgitation.

The technique is particularly suitable for minimally invasive mitral valve repair and serves as an alternative to sliding plasty in selected cases. 

The operative strategy was based on the implantation of the largest available annuloplasty ring to avoid interference with the free leaflet edges while reducing the functional height of the posterior leaflet to prevent systolic anterior motion (SAM). 

Surgery was performed through a video-assisted right minithoracotomy in the fourth intercostal space with femoral–femoral cardiopulmonary bypass. The mitral valve was exposed via a left atriotomy, providing excellent visualization. 

Valve assessment demonstrated symmetrical prolapse of all segments with elongated anterior and posterior leaflets.

Ring sizing was performed according to the anterior leaflet.  

After selecting the appropriate ring, mattress sutures were placed circumferentially. Posteriorly, pledgeted mattress sutures were used to achieve controlled plication and reduction of posterior leaflet height. 

Plication of approximately 5–10 mm is typically sufficient to displace the coaptation zone away from the septum and prevent SAM. Approximately 1.5 cm of posterior leaflet height was preserved to maintain an adequate coaptation surface. 

This approach was developed in response to cases in which even the largest annuloplasty ring did not sufficiently prevent SAM following repair. 

After ring implantation, the valve was tested with saline injection to assess competence and coaptation. The atriotomy was closed, cardiopulmonary bypass was discontinued, and intraoperative echocardiography confirmed an optimal result. 

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