PREOPERATIVE DIAGNOSIS: Mitral Regurgitation

OPERATION: Complex Barlow Mitral Valve Repair (Size 36 Physio Ring Annuloplasty; Posterior Leaflet Resection with Commissure to Commissure Sliding Plasty, Gap Closure P2, P3; Correction of Anterior Leaflet Prolapse with Posterior Leaflet Flip Technique x 2; Gap Closure P2, P3)

SURGEON: David Adams, M.D.

INDICATIONS FOR SURGERY: This patient is a 73-year-old man with a history of mitral valve prolapse that has progressed to moderate to severe degree of insufficiency. He was referred for elective surgical intervention.

OPERATIVE PROCEDURE: The mitral valve was exposed through Sondergaard's groove. Valve analysis revealed complex Barlow's disease. There was a giant prolapse and excess tissue of both leaflets with ruptured chordae involving P2 and A2. I began by performing a resection of P2, saving leaflet segments with basal chordae in the ventricle. The posterior leaflet was now detached commissure to commissure. Vertical and horizontal compression was done. The leaflet edges were reapproximated with running interrupted Prolene sutures. The gap was closed between P1 and P3. We now corrected the anterior leaflet prolapse with 2 transfers of the P2 segments with tissue and basal chordae. A true size 36 Carpentier-Edwards Physio ring was implanted. The valve had an excellent line of symmetry and normal saline and ink test.

POSTOPERATIVE ANALYSIS: The post-bypass transesophageal echo revealed absent residual regurgitation.

Transcript:

This is a 73-year-old man with Barlow's disease and severe bi-leaflet prolapse. He is asymptomatic. The echocardiogram reveals the anterior leaflet prolapse with a posteriorly directed jet. Valve analysis shows the ruptured chordae to the A2 segment, a very large valve, lot of excess tissue. Posterior leaf is very thick and 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 will 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 1 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. You see the asymmetry of that advancement which is common in Barlow's. The height of the leaflet and the closure line appears to be in good position. We now close the residual defect with interrupted Prolene, the true size is 36. We now correct the anterior leaflet prolapse by re implanting these posterior leaflet remnants with good secondary chordae into the margin of A2. We are not going to perform any resection in 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 and should be corrected at the margin by an interrupted suture.

Here is the final closure line after ring annuloplasty. There is good surface of coaptation and a very symmetric closure line.