1. Importance of Imaging for Degenerative and Barlow‘s Disease Michael A. Borger MD PhD Columbia University Medical Center New York Presbyterian

2. What Do I Want to Know From Pre-MV Repair Imaging? Direction of regurgitant jet Complex or simple MR jet Area of prolapse or leaflet restriction Location of unexplained jet Length of AML Length of left ventricle Distance to circumflex artery

3. P2 Prolapse: 3D TEE Assessment

4. P2 Prolapse: Assessing Pathology

5. P2 Prolapse: Loop Measurement

6. P2 Prolapse: Securing Loops to PM

7. Insertion of Loops on Leaflet

8. Water Test

9. Watch For „Secondary“ Lesions

10. Finding and Correcting „Secondary“ Lesions

11. A2 / A3 Cleft Closure

12. Post-Cleft Closure Water Test

13. Barlow’s Pathognomonic Findings Leaflet thickening Redundant tissue Chordal lengthening Bileaflet prolapse / billowing Annular dilatation +/- Calcification D. Adams

14. TTE View of Barlow’s Valve

15. Barlow’s Valve: Intraoperative Inspection

16. Stitch (Prolene 4-0) enters 1 cm from AML free edge and exits 1 cm from posterior annulus Edge-to-Edge Barlow’s MV Repair

17. Barlow’s Edge-to-Edge: Sealing Test

18. Post-Alfieri for Barlow’s Echo

19. Valve area: 3.0 cm 2 Gradient: 3 mm Hg (mean) Post-Alfieri for Barlow’s Echo

20. Relative Contraindications to Edge-to-Edge Barlow’s Repair - asymmetric prolapse - multiple flail segments - small annulus (rare)

21. Assymetric Barlow’s TEE

23. Assymetric (“bifid”) Barlow’s

24. Assymetric Barlow’s

26. Assymetric Barlow’s: Loop Repair

28. Assymetric Barlow’s: Assessing Repair

29. Thank you! mb3851@cumc.columbia.edu