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Mitral Valve Repair in Barlow's Disease Using PTFE Neochords and Annuloplasty: The Bending Plasty
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.