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.