Totally Endoscopic Repair of Barlow’s Valve With Simple Annuloplasty

In this CTSNet series, Dr. Mario Castillo-Sang presents innovative, totally endoscopic cardiac procedures for a variety of conditions. Stay tuned for more series videos in the coming weeks.       

The authors present the case of a totally endoscopic repair of Barlow's disease with complete annuloplasty. The case involved a 62-year-old male with Barlow’s disease, as shown on the transesophageal echocardiogram, which revealed bileaflet billowing and a prolapsing end-systolic central jet that was severe, along with a dilated annulus, dilated ventricle, and atrium. The patient had a slightly reduced ejection fraction and what appeared to be an indentation in the center portion of P2 toward the lateral aspect. The tricuspid valve was intact. The authors’ endoscopic approach consisted of a 2.5 cm working incision in the fourth intercostal space and a 10 mm port in the third intercostal space for a 30-degree angled endoscope. If the pericardial fat pad obstructs the view of the pericardium and phrenic nerve, it is important to resect it. The authors used a LigaSure device for this purpose. For exposure, the authors sometime use a diaphragmatic stitch with a pledgeted suture. 

The pericardiotomy was made 3 cm above the phrenic nerve. It was carried along the center portion of the aorta superiorly all the way to the diaphragm inferiorly, where it was directed toward the anterior aspect on the left side. In patients with poor venous drainage despite a large femoral venous cannula, an additional 16 French superior vena cava (SVC) cannula can be inserted through the incision. The surgeons used a second 5 mm port in the fourth intercostal space lateral to the internal thoracic artery for the placement of the atrial retractor, as well as passing retraction sutures and the ventricular pacing wire. A mattress pledgeted 2-0 polyester suture was placed in the ascending aorta for the cardioplegia needle. The ascending aorta was lifted anteriorly, the cross-clamp was applied, and the heart arrested with del Nido cardioplegia. The patient was cooled to 32 degrees Celsius, and the heart was arrested promptly. The surgeons entered the left atrium through Sondergaard’s groove and performed a sizable atriotomy extending toward the dome of the left atrium. The heart valve retractor was inserted, and the wing was lowered, allowing an unimpeded view of the mitral valve as well as a holder for the cardiotomy sucker. In this case, there was a large left atrium, and the surgeons performed a quick static test with del Nido cardioplegia using the laparoscopic suction irrigator. They found that placing the annuloplasty sutures first was helpful to fully and anatomically evaluate a valve with multisegment disease. Sometimes, the authors perform the leaflet repair first if pathology is limited to a single segment, such as isolated p2 prolapse, to facilitate suture management. In cases of a large left atrium and deep thoracic cavities, it is important to use extralong instruments. The HD 4K camera system helped with suture placement, and the camera showed the mitral regurgitation jet injury on the anterior atrium. 

After placing all the annuloplasty sutures, the valve was reevaluated with del Nido cardioplegia. In this pathology, it is common to see minimal prolapse; these valves are usually large, as demonstrated in the video using a 38 mm ring. An ink test was also performed to evaluate the coaptation zone. In this patient, the medial P2 to P3 area exhibited mild billowing. The surgeons placed a semi-rigid ring, Memo 4D, and secured it with titanium fasteners. The repair was competent, with a large coaptation zone, as demonstrated by the ink test. Patients with Barlow’s disease often have annular disjunction and curling of the ventricle. The authors believe that a better descriptor of this condition is end-systolic annular or basal eversion. The annulus extended outward and down, while the center portion of the ventricle curled inward, creating a functional bileaflet prolapse that was stabilized and resolved by the annuloplasty ring (1). The coaptation zone was vast. Static testing with del Nido cardioplegia using a suction irrigator showed a competent valve. For the closure of the left atrium, the authors left the retractor in place to allow visualization of the corners. 

The patient was weaned off bypass without any problems and did well. The postoperative echocardiogram showed a competent repair with a large area of coaptation and no residual mitral regurgitation. 

Discussion 

Barlow’s disease with multisegment involvement and presenting with an end-systolic central jet due to annular or basal eversion, can be repaired expeditiously with a mitral annuloplasty alone. In some cases, other techniques such as commissuroplasty or neochordal reconstruction can be added if warranted (2). The endoscopic platform lends itself to a cost-effective approach, allowing for faster healing and less pain. Barlow’s disease can often be repaired with nonresectional techniques that involve annuloplasty plus neochordal reconstruction (3). 

References

1. Barlow JB, Pocock WA, Marchand P, Denny DM. The significance of late systolic murmurs. Am Heart J. 1996;66: 443-52
2. Ben Zekry S, Spiegelstein D, Sternik L, Lev I, Kogan A, Kuperstein R, Raanani E. Simple repair approach for mitral regurgitation in Barlow’s disease. J Thorac Cardiovasc Surg. 2015; 150:1071-7
3. Lawrie GM, Earle EA, Earle NR. Nonresectional repair of the Barlow mitral valve: importance of dynamic annular evaluation. Ann Thorac Surg. 2009;88:1191-6

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