There are many ways to repair a mitral valve and I have always liked the “tool box” concept.  In other words, I think that you have to be prepared to use different techniques, for similar pathologies, in different patients.  I think that you cannot resort to only one technique to repair all valves. Not all valves are created equally.

I have been using the loop technique now for all anterior leaflet repairs and occasionally for posterior leaflet repairs. I know that everyone has there own concepts and tricks on using loops. I think that for the anterior leaflet the loops should be in front of the papillary muscles and for the posterior leaflet the loops should be behind them.  The trick here is that the loops need to be positioned between the chords when they are being attached to the posterior leaflet. I think that this concept is more anatomical from a chordal standpoint. The mitral collar provides unimpeded visualization of the entire infra-valvular apparatus. Furthermore, a mini-thoracotomy approach provides direct in-line, truly anatomical visualization of the mitral valve.

I would be interested in what others think.

1. The first picture shows the loops to the anterior leaflet positioned to the anterior aspect of the papillary muscle. The posterior loops are behind the papillary muscle and are tied anterior to the papillary muscle. The tied knot to the posterior loops is visualized anteriorly.

2. The second picture shows the posterior loops behind the papillary muscle and positioned between the individual chords. In other words, all the loops are not brought around the entire set of chords.

I have enclosed a link to the Annals of Cardiothoracic Surgery.
I have submitted 4 publications to this journal that I would like for all of you to review.
Two are relevant to Minimally Invasive AVR/MVR, one on Minimally Invasive AVR, and one on Building a Minimally Invasive Valve Program, of which I was a co-author with Dr. Tom Nguyen.
In addition, I think that all of the contributions to this journal are significant and will help advance the subspecialty of minimally invasive valve surgery.
I urge all to subscribe.
There are previous editions of this journal which are excellent and I believe serve as a reference for all Cardiothoracic Surgeons.
www.annalscts.com

I truly believe that the easiest way to perform a septal myectomy is through the mitral valve. The majority of cases that have severe MR secondary to SAM and septal hypertrophy will have a small anterior leaflet. There have been reports describing the detachment of the anterior leaflet chords and elongating them with artificial gortex neochordae to eliminate the SAM. I am sure this can be done but there is a more consistent solution. With SAM, MR and septal hypertrophy, I believe that detaching the anterior leaflet and extending the leaflet incision past the commisures, performing a septal myectomy and then suturing a pericardial patch to the defect in the anterior leaflet will resolve the problem. When performing the septal myectomy, I usually take a 3-0 silk needle and drive it into the thickened septum pull it down. Thereafter and 11 blade is used to incise the septum 3-4 mm from the aortic annulus. I will then use the long shafted metsenbaum scissor to complete an extensive myectomy. You can usually take more that you think. This approach will allow you to go deep into the septum towards the apex.

Over the years I have modified my technique for inserting the post for the atrial lift system.  Believe it or not,  patients were complaining about pain from this insertion site more than from the mini thoracotomy incision.

In the past I was making a small incision in the chest where I wanted to insert the post and thereafter passed a tonsil clamp from the incision and into the chest. I would then take a red rubber catheter , place it through the thoracotomy incision and pull it out through the small incision.  I would then use the red rubber catheter to guide the post back into the chest and later attach it to the blade.  I think that maybe the insertion of the clamp was just too traumatic.

Please view this short video to see the new technique that I strongly recommend.  I have provided the link below. (When you view it,  click on settings, which is the little pin wheel on the lower bar, third from the right.  This is the settings button. Click Quality and the select 720 HP. The resolution will be better)

If anyone has any suggestions or a better way, I would appreciate any comments.

I have tried this technique several times. I was skeptical at first but I was made a believer by Dr. Torsten Doesnt.  He told me that all anterior loops should be 24 mm and all posterior loops should be 12 mm,  regardless of the case. I am still a true believer of reconstructing the posterior leaflet with the classical resectional techniques. I just don’t like to leave so much excess leaflet in the ventricle.  I feel like I am leaving too much diseased tissue behind. I have tried different techniques for the anterior leaflet and this last one has made things even easier.

I was using the one loop with multiple small loops originating from it,  but this has made it even easier.  With the 3 loop technique, I sequentially attached the loops further onto the anterior leaflet with a 5-0 gortex suture as one moves laterally.  You can only chose to use only one or two loops and leave the 3rd one behind.

I know it sounds crazy but leaving the loops at 24-25 mm on all cases really works !!!

Watch this You tube video that explains how to do it.

Please give me your thoughts.

www.youtube.com/watch?v=ihg0w_HnKuU