Endoscopic Mitral Repair for Flail Anterior Leaflet Using a Periareolar Incision

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In this video, the authors describe the repair of an anterior mitral leaflet damaged by endocarditis using a periareolar incision The patient was a 65-year-old male presenting with dyspnea on exertion. The patient’s workup showed a flail anterior leaflet resulting from an episode of endocarditis. The transesophageal echocardiogram showed a severe posteriorly directed jet and a flail medial anterior leaflet. Cannulation was performed via femoral access. 

The periareolar incision was performed by entering at the fifth intercostal space. A camera port was inserted in the fifth intercostal space, and a 5 mm port was inserted in the fourth intercostal space with CO2 being insufflated. A Chitwood clamp was used, and the heart was arrested using del Nido Cardioplegia. Intraoperative analysis showed a medial A2 chordal rupture. The repair was performed with two CV4 neochordae. Using saline testing, the neochordae were adjusted for the correct height. A third polytetrafluoroethylene (PTFE) suture was inserted on the medial muscle to correct a residual prolapse. Annuloplasty sutures were placed from trigone to trigone, and a 30 mm incomplete band was used for the annuloplasty. Static testing and ink testing demonstrated a good repair. Postoperative transesophageal echocardiogram (TEE) showed complete resolution of the mitral regurgitation with a mean gradient of 2 mmHg. The patient was extubated within two hours and was discharged three days later. 

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