In this video we are going to review mitral valve repair techniques in three cases of complex Barlow valve disease.
The first patient is a 51-year-old female with bileaflet prolapse. She is asymptomatic. The echocardiogram shows a significant amount of excess tissue particularly in the posterior leaflet with displacement of the posterior leaflet toward the left atrium and an anteriorly directed jet. Valve analysis reveals multisegment excess tissue predominantly in the P2 segment and to a lesser extent P3. P1 is somewhat restricted and we are going to use this indentation as our cut site between P1 and P2. We will not resect all of the P2 segment, but just the tallest portion of it and then we will detach the residual P3 and P2 segments. We are going to cut some more excess tissue off this residual segment and you will notice a good secondary chord attached to the segment of the leaflet. We typically will save this in the ventricle in case we have a residual prolapse. We now perform a vertical plication of the annulus and then a horizontal plication. This allows us to perform a leaflet advancement or sliding plasty with minimal tension. You can see we are using a 5-0 Prolene suture to reimplant the detached leaflet in the atrioventricular groove. Saline testing confirms good posterior location of the closure line. We now can close the residual leaflet defect. We prefer interrupted Prolene for this. We now measure the anterior leaflet surface area, a 36 sizer and after implantation of remodeling ring a tendency to A2 prolapse. We will correct this with the residual posterior leaflet segment with a good secondary chord attached to A2. Saline testing reveals continued tendency to prolapse of the small segment. We will correct this by attaching this posterior leaflet remnant along the margin of A2. This results in an excellent line of coaptation of posterior displaced closure line and a good surface of coaptation.
The second case is a 59-year-old woman with Barlow’s disease and complex posterior leaflet prolapse. She also has atrial fibrillation. You can see displacement of the posterior leaflet away from the atrioventricular groove and an anteriorly directed jet. A complex multi scalloped posterior leaflet, diffuse thickening, early calcification of the annulus, deep indentations between P1, P2, and P3, and calcification and retraction of the anterior papillary muscle. We center our resection around this area. This is a common finding in advanced Barlow’s disease with calcification and retraction. This all needs to be removed to free up the residual leaflets, so we will center our resection around this area of the valve removing both the leaflet as well as the calcified or fibrotic papillary apparatus here. We are going to close this indentation or scallop between P3 and P2 so we can treat these two segments now as a single segment in terms of our leaflet advancement. We will detach P3 and P2 from the posterior commissure. You see us resecting additional posterior leaflet tissue trying to make the height a centimeter, a vertical plication of the annulus, and this will allow us to perform our leaflet sliding plasty with minimal tissue. I use a 5-0 Prolene to reattach the remnant of the posterior leaflet in the atrioventricular groove. We are going to close this indentation between P3 and P2 with imbricating interrupted sutures, and then we will close the defect from our sliding plasty with more interrupted suture. Here is the reconstituted posterior leaflet. The anterior leaflet height measures 38 and notice the inter-commissure distance is somewhat narrow at 36. This is not uncommon in Barlow’s disease with a normal valve ratio is often not observed. In this scenario, we will adjust the ring. You see the closure line; somewhat generous residual posterior leaflet. To minimize the risk of SAM (systolic anterior motion), I am going to open up a 36 ring to beyond a size 38. Despite that maneuver, you see the closure line is still in the middle of the valve with a significant amount of anterior leaflet tissue below the coaptation surface. To correct this we are going to continue to lower the height of the posterior leaflet by adjusting the height with a Gore-Tex chord. After doing that you can see the final reconstruction with no evidence of SAM (systolic anterior motion) and a very symmetric closure line.
Third case is 73-year-old man with Barlow’s disease and severe bileaflet prolapse who is asymptomatic. The echocardiogram reveals the anterior leaflet prolapse with the posteriorly directed jet. Valve analysis shows the ruptured chordae to the A2 segment, a very large valve, a lot of excess tissue, posterior leaflet is very thick, microcalcification of the annulus. We are going to perform a leaflet resection and preserve this portion of the posterior leaflet with good secondary chords to correct the anterior leaflet prolapse later. We leave those in the ventricle and detach the remaining segments of the posterior leaflet from the commissure. You see us doing a resection of the base of this remnant to lower the overall height to a cm. We will cut all of the secondary chords in order to allow us to do a leaflet transfer with no restriction. We prefer a simple interrupted technique to perform a vertical annular plication. This is again important to take tension off our leaflet advancement which we are now performing with a running Prolene suture. See the asymmetry of that advancement which is common in Barlow’s disease. The height of the leaflet in the closure line appears to be in good position. We now close the residual defect with interrupted Prolene, true size is a 36. We now correct the anterior leaflet prolapse by reimplanting these posterior leaflet remnants with good secondary chordae into the margin of A2. We are not going to perform any resection of the anterior leaflet in this case and correct the prolapse by this posterior leaflet flip technique. You can see the small residual defect between P1 and the transferred P2. This is not uncommon. It should be corrected at the margin by an interrupted suture. Here is the final closure line after ring annuloplasty with good surface of coaptation and a very symmetric closure line.
Thank you for your attention.
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