PREOPERATIVE DIAGNOSIS: Barlow's Mitral Valve Disease

OPERATION: Complex Barlow's Mitral Valve Repair (Bileaflet Prolapse; Posterior Leaflet Quadrangular Resection; Vertical and Horizontal Compression followed by Sliding Plasty; Magic Suture x 1 to Posterior Commissure; Chordal Transfer x 1 to Correct A2 Prolapse; Gore-Chord x 1 to Correct A2-A3 Prolapse; Gap Closure A2-A3; True Size 36 mm Physio II Ring)

SURGEON: David Adams, MD

INDICATIONS FOR SURGERY: This 69-year-old patient has a giant Barlow's valve with severe mitral valve regurgitation referred for elective intervention.

OPERATIVE PROCEDURE: The mitral valve was exposed through Sondergaard's groove. Valve analysis revealed complex Barlow deformity with bileaflet prolapse. A quadrangular resection of P2 was performed followed by the attachment of P1-P3 with extensive sliding plasty after vertical horizontal compression. We then saved a portion of the posterior leaflet with a good chord and flipped it to the A2 segment where we had clear ruptured chordae. A second Gore-Tex chord was added between A2 and A3. Magic sutures were used to correct posterior commissural prolapse. A true size 36 mm Physio II ring was implanted. I then finally closed a gap between A2 and A3. The valve had an excellent line of symmetry and a normal saline test.

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

Video Transcript:

I am Dr. David Adams, The Chairman of Heart Surgery at Mount Sinai Medical Center. Today I would like to show you a video of mitral valve repair utilizing the new Carpentier-Edwards Physio II Ring of which I am a co-inventor.

The case I would like to show is a 69-year-old man with diffuse and complex mitral valve regurgitation with bileaflet prolapse, which is multisegmental in nature. The patient has a complicated jet with multiple areas of malcoaptation. When we fill the ventricle; the valve obviously has a lot of excess tissue, ruptured chords in the anterior leaflet, very tall segments in the posterior leaflet, and a very abnormal and dilated annulus.

The first step in a case of bileaflet prolapse with excess tissue is to remodel the posterior leaflet; in this case we are cutting out a segment of the middle scallop of the posterior leaflet. We will always preserve secondary chords from the posterior leaflet and leave them in the ventricle to help address the anterior prolapse later. Now we are using a knife to dissect the remainder of the posterior leaflet off the atrioventricular junction, and it is important that we then cut the secondary chords underneath the leaflets, so that when we transfer the chord along the margin of the annulus, it does not get restricted. Here you can see I am making a horizontal resection in the leaflet, as one of our goals is to have residual leaflet heights of approximately 1 cm. We now detach the P1 segment toward the anterior commissure sharply from the annulus and then go through the same step of mobilizing the base of the leaflet. We are now going to place compression sutures. What compression sutures will do is help us narrow the annulus, so we will put a row of these sutures in and we can use these for plication of the annulus and now we have put these sutures which will tighten and narrow the annulus. The second type of suture we can place is a horizontal plication suture, and you can see we have taken a bite of the annulus and a bite of the ventricle and then come back through the annulus so when we tie this it plicates the annulus and narrows it. This other row of sutures we are tying is a vertical plication of the annulus, so now we have narrowed the annulus to approximate the height.

The next step is to reconstruct the posterior leaflet. We will do that with a running suture technique, where we will sew the posterior leaflet now at the correct height back into its correct location into the narrowed annulus. The key step here is to remodel the posterior leaflet. We know we can correct the anterior leaflet prolapse, but we will only address that after we have corrected the shape and position of the posterior leaflet.

Now, after we have corrected the posterior leaflet, we need to get ready to address the anterior leaflet prolapse. There are two ways we can do that, we will place Gore-Tex chords in the papillary muscle and we will use these residual chords from the posterior leaflets, which we preserved to begin to correct the anterior leaflet position, so you can see we are now attaching the posterior leaflet chord into the margin of the anterior leaflet in the area of the chordal rupture. This will get us started in terms of adjusting the height of the leaflet. Now within we will mark additional areas of prolapse, and place Gore-Tex chords into those areas and you can see now as I adjust the height of that with the ventricle under saline, we can now put the anterior leaflet margin back into its correct position below the annular plane. Now we are sizing the ring based on the surface area of the anterior leaflet. We have implanted a size 36 Physio II Ring, and now we fill the ventricle with saline to confirm an excellent closure line and a completely competent valve.