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Standardized Strategy for Repair of Barlow symdrome via Minimally Invasive Approach
Jan-Philipp Minol, Payam Akhyari,
Udo Boeken, Tobias Weinreich, Hildegard Gramsch-Zabel, Hiroyuki Kamiya, Artur Lichtenberg.
University Hospital, Duesseldorf, Germany.

Objective: The Barlow syndrome defined as prolaps of the both leaflets with excessive tissue is sometimes difficult to repair. Here we present our technique for surgical treatment of Barlow syndrome with minimally invasive approach. Methods: At first, the whole mitral valve is inspected. Then, the P2-segment will be widely resected as triangular or quadrangular tissue after trimming and leaving the shortest chordae, normally the basal chordae at the P2-segment. This trimmed P2-segment will be transferred to the A2-segment. For this chordal transfer, the trimmed P2-segment will be sutured onto the top of the A2-segment on the ventricular side. In cases of quadrangular resection of the P2-segment, the annulus will be locally plicated. Then, the resected margins will be sutured in a running fashion. If the posterior annulus is severely calcified, the whole posterior leaflet will be detached from the annulus and annular decalcification will be done. Then, the P2-segment will be resected and chordal transfer will be done as described above and the posterior leaflet will be reconstructed as the sliding plasty including suturing the resected margins and re-attachment of the entire posterior leaflet to the annulus. Thereafter, an open annuloplasty prosthesis (in our hands Medtronic Future-Band) will be implanted. Results: Between August 2009 and August 2013, 22 patients (11 males, mean age 56 years old) with Barlow syndrome underwent video-assisted minimal-invasive mitral valve surgery via right mini-thoracotomy using this technique. No residual mitral valve regurgitation was seen in all patients. A slight systolic anterior motion (SAM) was seen in only one patient, which could be treated successfully with β-blocker medication. Conversion to full sternotomy was necessary in one patient (4.5%) due to injury of the circumflex artery. Early mortality was 0%. During follow-up, one patient died due to gastrointestinal bleeding. No patients needed reoperation for recurrence. Conclusions: This technique facilitates repair of Barlow syndrome with complex morphology and is durable in midterm follow-up.

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