Mitral Valve Repair P2 Prolapse: Triangular Excision

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.