1. A Novel Method of Leaflet Reconstruction After Triangular Resection for Posterior Mitral Valve Prolapse 
Rakesh M. Suri, MD, DPhil, Harold M. Burkhart, MD, Hartzell V. Schaff, MD 
The Annals of Thoracic Surgery 
Volume 89, Issue 6, Pages e53-e56 (June 2010)
DOI: /j.athoracsur
Copyright © 2010 The Society of Thoracic Surgeons Terms and Conditions

2. Fig 1
(A) Left atrial “surgeon” view of the mitral valve demonstrating tall myxomatous middle scallop of the posterior mitral leaflet. (B) After triangular resection of the majority of the middle scallop of the posterior leaflet, the tall remaining lateral and medial borders remain, which rise well above the commissural plane. Suture reconstruction using the ventricularization technique is performed to normalize the height of the posterior leaflet. The initial stitch is taken in a mattress-type fashion from the atrial side of the leaflet through the prior leading edge, and then in reverse through the opposite side. (C) The initial mattress stitch is tied with three knots, followed by visual confirmation that the chosen degree of leaflet shortening corresponds to the ideal height of the neo-posterior leaflet. (D) Each needle is used to reconstruct the posterior leaflet in sequence to create a water-tight, two-layer suture line. (E) The stitch is tied at the base of the resection, which need not necessarily extend to the mitral annulus.
The Annals of Thoracic Surgery  , e53-e56DOI: ( /j.athoracsur )
Copyright © 2010 The Society of Thoracic Surgeons Terms and Conditions

3. Fig 2
(A) Preoperative transesophageal echocardiogram demonstrates severe bi-leaflet mitral valve prolapse. (B) Torrential mitral valve regurgitation with multiple regurgitant jets emanating from all six mitral scallops during systole.
The Annals of Thoracic Surgery  , e53-e56DOI: ( /j.athoracsur )
Copyright © 2010 The Society of Thoracic Surgeons Terms and Conditions

4. Fig 3
(A) Robot-assisted mitral valve repair in the setting of severe Barlow's mitral valve disease. High-definition visualization of bi-leaflet mitral valve prolapse involving all six mitral scallops. (B) Triangular resection of the middle scallop of the posterior mitral leaflet. (C) Posterior leaflet ventricularization and placement of the first height-setting mattress stitch. (D) Two-layer Prolene (Ethicon, Somerville, NJ) reconstruction. (E) Completed suture line prior to tying of the stitch. (F) Placement of a standard length flexible 63-mm posterior annuloplasty band using interrupted Ethibond sutures, which were then tied by the bedside surgeon using a knot pusher.
The Annals of Thoracic Surgery  , e53-e56DOI: ( /j.athoracsur )
Copyright © 2010 The Society of Thoracic Surgeons Terms and Conditions

5. Fig 4
Post-repair intraoperative transesophageal echocardiogram demonstrating (A) robust leaflet coaptation during systole, and (B) freedom from residual mitral regurgitation.
The Annals of Thoracic Surgery  , e53-e56DOI: ( /j.athoracsur )
Copyright © 2010 The Society of Thoracic Surgeons Terms and Conditions