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Repair of Barlow’s Disease: The 4-Chords Technique

Tuesday, June 25, 2019

Hodges K, Chemtob R, Mick S, Gillinov AM, Wierup P. Repair of Barlow’s Disease: The 4-Chords Technique. June 2019. doi:10.25373/ctsnet.8290433.

This video demonstrates a straightforward, reproducible technique for the repair of bileaflet prolapse in Barlow’s disease. The valve is repaired with two sets of chordae to each of the anterior and posterior leaflets. The key technical consideration is the sizing of the chordae. For the anterior leaflet, chordae are sized by pulling the leading edge of the leaflet to the corresponding hinge-point on the mitral annulus. Posterior chordae are sized to be very restrictive and should result in the posterior leaflet being pulled straight down on postoperative echocardiogram.

For robotically-assisted repairs, several modifications to the standard Gore-Tex suture facilitate ease of use: a knot is tied in the suture a measured distance from the needle (15 cm for anterior chordae and 13 cm for posterior chordae) and the segment of suture immediately proximal to the knot (15 mm for posterior chordae and 20 mm for anterior chordae) is colored black, as a reference for sizing. The repair is finished with a posterior annuloplasty, using the largest possible flexible band. These maneuvers ensure that the coaptation point will be as far posterior as possible, to mitigate the risk of postoperative systolic anterior motion (SAM). For the repair shown in the video, there is no postoperative mitral regurgitation and no SAM, with a very posterior coaptation point.

Additional Resources

Ragnarsson S, Sjögren J, Stagmo M, Wierup P, Nozohoor S. Assessment of mitral valve repair with exercise echocardiography: artificial chordae vs leaflet resection. Semin Thorac Cardiovasc Surg. 2017;29(1):25-32.


It’s great to see robotics continue to grow and mature in our specially. The robot will be an important tool in the new era of catheter-based options being available. High-quality durable repairs done in high-volume centers minimally invasively will keep surgery relevant to our patients.

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