How I Assess and Repair the Barlow Mitral Valve: The Edge-to-Edge Technique

Abstract

The main cause of mitral regurgitation (MR) in the western world is degenerative mitral valve disease, which usually leads to prolapse or flail of the posterior, anterior, or both leaflets. Mitral valve repair has become the treatment of choice of degenerative MR providing predictable and durable results in most patients.^1,2 The most favorable outcomes have always been reported with isolated prolapse of the posterior leaflet treated by a simple procedure like quadrangular resection and annuloplasty. On the other hand, less gratifying results and more demanding surgical techniques have been associated with correction of mitral regurgitation due to anterior leaflet or bileaflet prolapse.^3–6 To increase the feasibility of repair in those more difficult settings, a new surgical technique, named edge-to-edge, was introduced by our group more than 15 years ago. The basic principle of the edge-to-edge is that the competence of a regurgitant mitral valve can be restored with a functional rather than an anatomical repair. This can be obtained by suturing the free edge of the diseased leaflet to the corresponding edge of the opposing leaflet, exactly at the site where regurgitation occurs. When the regurgitant jet is located in the central part of the mitral valve, the application of the edge-to-edge technique produces a mitral valve with a double orifice configuration. In this case, the operation is conventionally defined as double orifice repair, and the two orifices can have similar or significantly different sizes depending on the extension and location of the suture performed. On the other hand, when the regurgitant jet is located in the commissural area, the application of the edge-to-edge technique at this level creates a single orifice mitral valve with a relatively smaller area. This second instance is usually called paracommissural edge-to-edge. There are situations in which the regurgitant jet of the mitral valve is not a single one. Particularly, in the setting of Barlow’s disease with severe bileaflet prolapse, for example, multiple regurgitant jets are usually found along the entire line of coaptation of the anterior and posterior leaflet. In this case, the edge-to-edge approximation of the middle scallop of the anterior and posterior leaflet (A2 and P2) allows the elimination of most of the mitral insufficiency while the residual smaller regurgitant jets are effectively corrected by the association of a ring annuloplasty.