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In our Mitral Foundation Video Teaching Library we are going to show a series of cases that demonstrate teaching points in the field of mitral valve reconstruction.
When you have a multi-segmented Barlow's, rather than cut out the tallest segment, sometimes you want to do a targeted resection of a less tall segment using the indentation as one side of your resection. Then, when you detach the tall segment and perform a sliding leaflet plasty, you'll see that you really preserved the maximum amount of leaflet for coaptation and that you can do this without creating any tension on the suture lines and avoid the need for angular annular compression.
Our main strategy for treating patients with excess posterior leaflet tissue is sliding leaflet plasty. We follow Carpentier's rules, usually performing a limited quadrangular resection. We do resect less tissue today than we did historically, and then we reattach the leaflet along the annulus. Annular plication is sometimes used to narrow the orifice and take tension off the leaflet.
Triangular resection is a simple technique. It's designed to correct prolapse at the margin of the leaflet. As demonstrated in this case, adjusting the width and depth of the triangular resection will allow you to tailor the body of the leaflet to the correct height and deal with myxomatous degeneration that may be present.
The key teaching points that we show in this video is patch augmentation is the primary strategy for a perforation, whether that's healed or acute in the anterior leaflet.
There are a variety of repair strategies that are useful for anterior leaflet prolapse. In this video, we're going to show a technique of single suture PTFE, placed in the tip of the papillary muscle and passed through the free edge, with final height adjustment during saline testing; a functional height adjustment, as opposed to geometric adjustment.
In this video we show an example of a reconstruction of Barlow's valve disease in a patient that has calcification of the annulus. The key steps we'll show are a detachment of the leaflet with a targeted de-calcification of the annulus and then reconstruction of the posterior leaflet and finally ring annuloplasty.
High velocity jets after mitral valve repair strongly suggest leaflet perforation. They're usually simple lesions to re-repair. And if patients are stable and have good ventricular function, it's usually worth a second look on bypass to identify them. They can be dynamic and they can also happen from a pressurized ventricle and when you see them, you shouldn't just trust the sailing test, you should go back on and reexamine the valve.
Systolic anterior motion occurs after mitral valve repair due to an excess of leaflet tissue versus the anterior lateral height of the orifice of the mitral valve. The posterior leaflet pushes the anterior leaflet into the outflow tract. There are two principal causes for this. One is excess height of the posterior leaflet after reconstruction. The second one is a ring size that is too small for the available leaflet tissue. In either circumstance, the posterior leaflet will coapt at the midpoint of the anterior leaflet, and the tip of the anterior leaflet is pushed into the outflow tract.