This patient is a 33-year-old male patient with a long history of a cardiac murmur who was recently noted by his cardiologist to have severe mitral regurgitation and so was referred for surgical treatment.

Echocardiography shows bi-leaflet prolapse with features typical of Barlow’s disease. The mitral valve has been exposed. Notable features are a large anterior leaflet, a tall posterior leaflet in the P3 segment shown here, restriction of the mid-segment of the posterior leaflet with a calcified mass of papillary muscles and chordae seen below, a tall P2 segment of the posterior leaflet, and a normal sized P1 segment. Also noted are two ruptured chordae to the posterior leaflet P2 segment.

We are first closing the cleft between P1 and P2, which will make subsequent alignment of the leaflet more straightforward. Following this, we can now resect the mid-segment of the P2. We are now examining the valve again and seen is the calcified mass. It is a 1 cm mass which involves chordae to the P2 segment causing a 3A restriction in this region. Here we are dividing secondary chordae to this area to release the leaflet. We are now deciding on our area of resection and will resect the entire restricted portion of the posterior leaflet.

Initially, we make a small resection and then as the repair goes along we can adjust and resect more tissue as required. We are now completing the excision of the calcified leaflet with the attached mass. We are then performing a detachment of the P3 segment from the posterior commissure to the entire mid-annulus to the area of prior resection. Secondary chordae are divided to further mobilize the detached leaflet segment and prevent restriction after repair. The annulus has been plicated to reduce tension on the reconstituted leaflet. Next, we are excising an additional segment of P2, as there is abundant P3 to slide to reconstitute the posterior leaflet. Marks are placed on the posterior leaflet and also on the annulus to allow accurate re-approximation. We then re-attached the leaflet with a sliding technique. This is done with a double-layer of 4-0 Prolene sutures and is performed in such a way that we will have a residual height of around 12 mm of posterior leaflet.

The anterior leaflet is now sized and found to be at 38 mm. To correct the anterior leaflet prolapse, we are placing some Gore-Tex sutures within the anterior papillary muscle and subsequently the posterior papillary muscle, which will be used to correct residual prolapse. The posterior leaflet had previously been re-approximated at the P1 and reconstituted P2 segments and annulus sutures have been placed around the entire annulus.

It is best to place these Gore-Tex sutures at this point. As once the annuloplasty ring is placed, it could be difficult to gain exposure to the sub-annular structures. The ring is in place and the valve is tested showing anterior leaflet prolapse. The areas prolapsing have been marked with a marking pen and the Gore-Tex chords are now being attached to the margin at this point.

We will attach two Gore-Tex chords to the A3 segment and one Gore-Tex chord to the A2 segment. The fourth Gore Tex chord will be used to reinforce the posterior leaflet repair. We prefer a dynamic method of adjusting the lengths of these chordate. For this we first tie two simple knots and then we distend the ventricle with saline, as shown, and then adjust the lengths of the chords as appropriate. Here, we can still see some residual prolapse. This would mean the suture needs to be tied to achieve a shorter length; this is being done now.

The valve will be tested again; at this point, the A3 segment is no longer prolapsing. We then complete our knots to achieve a final length. This is a completed repair which shows a symmetrical closure line with a good ratio of anterior to posterior leaflet. The ink test shows a 1-cm zone of coaptation. Postoperative echo confirms adequate zone of coaptation with minimal residual regurgitation.