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Usefulness of Leakage Test in Mitral Valve Repair

Tuesday, May 25, 2021

Torre TM, Toto F, Ferraris E, et al. Usefulness of Leakage Test in Mitral Valve Repair. May 2021. doi:10.25373/ctsnet.14673558

Mitral valve repair is the preferred surgical treatment for mitral regurgitation. Minimally invasive technique through right minithoracotomy is routinely performed for treating this pathology for complex repair too. Cardiac surgeons must increasingly pursue high-quality mitral valve repair, which ensures excellent long-term outcomes. In this video, the authors have collected some particular cases in which there was a discrepancy between a good or not satisfactory at all leakage tests after mitral valve repair and the echocardiographic findings.

Intraoperative assessment of a competency of the repaired mitral valve before closure of the atrium is an important step in accomplishing successful mitral valve repair.

Saline test is the most simple and popular method to evaluate the repaired valve. But this kind of test in an arrested heart may not accurately reflect its function in a contractile heart and it is not always reliable because of variable physiological factors that could influence its safety.

Perfusion techniques during beating heart surgery by antegrade coronary artery perfusion without aortic cross-clamping, and retrograde coronary artery perfusion via the coronary sinus with aortic cross-clamping have been advocated as alternative methods of mitral valve assessment after repair.

The mitral valve is not a “static” valve because all its components are involved in its competence: the annulus, the leaflets, chordal apparatus and papillary muscles. During systole the left ventricular apex moves towards the mitral plane and papillary muscles contract and the cordae stretched. At the same time the mitral annulus reduces its surface of about 20-30% enhancing mitral competence. At the same time the evaluation of a residual insufficiency could be compromised by the anterior leaflet traction due to atrial retractor.

The natural consequence of this considerations is that a leakage test in an arrested heart in dyastole could not be considered a competence proof as in normal contractile conditions.

The cases presented in this video represent only a small cohort of patients in which a leakage test resulted detrimental for competency proof.


  1. Chemtob RA, Wierup P, Mick SL, et al. Intraoperative Assessment of Mitral Valve Repair: Validation of the Saline Test With Nonresectional Repair Techniques.
  2. J Card Surg. 2019 Oct;34(10):965-968. doi: 10.1111/jocs.14167. Epub 2019 Jul 12.
  3. Yanase Y, Sato H, Yamada H, et al. Intraoperative Evaluation for Residual Mitral Valve Regurgitation; Usefulness of the Retrograde Cardioprotective Beating Test. Kyobu Geka. 2014 Sep;67(10):888-90.


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Thank you for your valuable comment. In that case we converted our approach to median sternotomy and performed an ascending aorta replacement and an arch and descending aorta remodeling using an AMDS (Ascyrus Medical Dissection Stent).
Dear Andrew, thank for your question. For remeding to this bothering problem we now try to reproduce the left ventricular distension by means of overfilling with saline solution. As explained in the video this is not the only tool for valve competence evaluation, but it can simulate a better leaflet coaptation.

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