Chord transfer and leaflet management for Barlow’s valve repair

Figure 1. Quantitative algorithm-guided surgical technique based on A2 anterior leaflet length measurement is our preferred approach. Normal A2 length ranges from 18–22 mm; in patients with degenerative mitral regurgitation (DMR), the average increases to approximately 28 mm. A2 lengths >30 mm are common in Barlow’s disease and may exceed 40 mm, with excess tissue contributing to post-repair systolic anterior motion. Posterior leaflet prolapse occurs in 80% of cases without anterior leaflet involvement, most often involving an elongated P2 segment averaging 20 mm (normal 8–12 mm).

Figure 2. The free edge margins on either side of the anterior leaflet prolapse are marked with 4-0 Prolene sutures to assist visualization and chord transfer planning. Posterior leaflet marking sutures on each side of the prolapsing segment are not shown in this illustration. In bileaflet disease, the prolapse typically measures 10–15 mm along each leaflet free edge. Anterior leaflet prolapse is corrected using a classic Carpentier technique, employing the patient’s own tissue rather than Gore-Tex neochords. The insert indicates that excess leaflet tissue out to the free edge is included in the resected portion. It should be trimmed away so that just the chords with some overlying leaflet tissues are transposed. Typically, the section of chords with leaflet tissue that is transferred is about 4 mm wide. Rarely, if desired, the section of leaflet can be split in half, and the chords will cover a wider section from A1 to A3.

Figure 3. The free edge ruptured chords should be excised, and excess tissue should also be trimmed so that only the chords and overlying leaflet tissue are transposed. The selected posterior leaflet segment is aligned with the prolapsing portion of the anterior leaflet, secured with sutures at the medial and lateral margins to ensure correct orientation and avoid rotation or entanglement. Sutures are placed full-thickness through both leaflet free edges; the leaflet tissue allows a few millimeters of stretch to cover the prolapsed area. Leaflet reconstruction is performed with 5-0 braided sutures, which provide soft, low-profile knots and greater flexibility than Prolene.

Figure 4. Between the medial and lateral anchoring sutures, three to four full-thickness figure-of-eight sutures are placed, with additional simple sutures at each end to smooth irregularities. Reducing uneven leaflet surfaces prevents small coaptation jets sometimes seen on intraoperative echo; these minor jets usually resolve on follow-up studies. The aim is complete elimination of mitral regurgitation on post-repair transesophageal echocardiography (TEE).

Figure 5. Achieving optimal leaflet coaptation length is the primary objective of mitral valve repair. Viewing the repair both in cross-section and from the surgeon’s perspective illustrates the completed chordal transfer from the posterior to the anterior leaflet.

Figure 6. Chord transfer is performed before posterior leaflet reconstruction to visualize the subvalvular apparatus and ensure chords are not twisted. The resection base usually leaves a 2–6 mm annular gap, closed with a 2-0 braided plication stitch. Tightening and securing it to the drape rotates the valve toward the surgeon for better exposure. Posterior leaflet reconstruction follows the standard algorithm, maintaining a 2:1 anterior-to-posterior leaflet ratio. Using calipers, the posterior height is set—for example, with an A2 length of 28 mm, P2 is reconstructed to 14 mm via a partial folding plasty. 5-0 sutures placed just below the target height fold the leaflet precisely. Each new free edge is supported by adjacent chords and adjusted for asymmetry. This reproducible technique has largely replaced sliding plasty (<1% of repairs) and ensures optimal coaptation height.

Figure 7. Leaflet closure is performed in two layers with running 5-0 braided sutures, though Prolene is acceptable. The first layer is full-thickness, and the second smooths the leaflet surface at the coaptation zone to minimize small residual jets. If trivial or mild MR appears on post-repair TEE, confirm the jet originates from the coaptation zone and not the suture line. Surface jets are typically stable, with no effect on long-term durability, but a mid-body suture-line jet can enlarge and should be repaired with a small pericardial patch. After resection, segmental indentations (P1–P3) may widen; clefts extending >50% toward the annulus are routinely closed (~80%) to prevent jets and ensure even chordal tension. This method achieves <mild MR in 94% of intraoperative TEEs. MR, mitral regurgitation; TEE, transesophageal echocardiography.

Figure 8. Final saline testing confirms valve competence. In Barlow’s disease, small leaflet edge irregularities may create minor coaptation jets; marking them with blue ink aids identification after drainage. Over 90% close with a simple 5-0 suture, and added stitches smooth the coaptation zone. The repair should be symmetrical—any asymmetry may indicate subtle prolapse or restriction, often clarified by reviewing pre-repair TEE. Minor defects are corrected with commissuroplasty or free-edge remodeling. A complete remodeling ring standardizes anterior–posterior closure and ensures long-term durability and compatibility with future valve-in-ring therapy. TEE, transesophageal echocardiography.

Figure 9. Proper coaptation length is determined by the AP diameter of the ring. Traditional sizing by commissure-to-commissure, trigone-to-trigone, or anterior leaflet area does not achieve consistent results. The illustration shows that identical leaflet lengths can yield a target CL of 5–10 mm across a range of ring sizes, preventing SAM and ensuring durability. After prolapse correction, the combined leaflet length is distributed within the AP ring distance. For example, with A2=28 mm and P2=14 mm (total 42 mm), a ring with AP =28 mm provides a 14 mm CL (7 mm per leaflet; A), while an AP =22 mm yields 10 mm CL (B). Targeting an 8 mm CL works well. For the leaflet lengths in this illustration, total overlap of 16 mm produces it (42−16=26 mm AP). A ring with an AP of 26 mm thus provides ideal coaptation. Using this mathematical approach, consistent 5–10 mm CL has been achieved in 100% of repairs, with 90% within ±2 mm of the 8 mm target. AP, anteroposterior; CL, coaptation length; SAM, systolic anterior motion.