Decision-making in mitral valve repair: Crucial points from 3 posterior leaflet cases

Video clip is available online.Surgical mitral valve repair is the gold standard for degenerative mitral regurgitation (MR).For posterior leaflet disease, mitral valve repair is the expectation, and repair surgeons are held to a very high standard.1 Three cases are presented for educational review, highlighting crucial decision-making steps when repairing single-scallop degenerative disease involving the posterior leaflet (Video 1).All cases are robotic-assisted, using repair techniques adapted to the robotic platform.2 Informed consent was obtained for the publication of these study data; institutional review board approval was not required. CASE 1A 23-year-old male patient presented with dyspnea on exertion and decreased exercise tolerance.A typical P2 prolapse was observed, with thickened but nonprolapsing adjacent scallops and normal chordae.After the margins of the excessive P2 were defined, a typical triangular resection was performed.Leaflet resection margin alignment was confirmed, and the resection was closed using interrupted 4-0 polypropylene suture in an imbricating figure-of-8 fashion, ensuring a smooth surface for coaptation.Annuloplasty was completed with a 31-mm flexible band, and static testing demonstrated deep and posterior coaptation without residual prolapse or significant MR.This finding was confirmed on final intraoperative transesophageal echocardiography (TEE).There was no residual MR, no systolic anterior motion (SAM), and minimal mean gradient. CASE 2A 50-year-old male patient presented with dyspnea on exertion and fatigue.He was found to have P2 flail and a focal severe anteriorly directed MR jet.A small incidentally found fibroelastoma was removed.A very tall flail P2 was encountered.Margins of abnormal tissue were defined; the triangular resection was performed and reconstructed using interrupted imbricating 4-0 polypropylene figure-of-8 sutures.The annuloplasty was completed using a 33-mm flexible band.VIDEO 1. Demonstration of 3 posterior leaflet cases, and each of the decision-making processes leading to successful repair.Video available at: