Minimally invasive repair of posterior leaflet mitral valve prolapse with the "respect" approach.

Prolapse of the posterior leaflet (PPL) was the first lesion accessible for repair (1) and currently represents the most common cause of mitral regurgitation in a western population. Alain Carpentier conceptualized and developed the “functional approach” for mitral valve reconstruction, which aims to restore the coaptation surface (2). Leaflet resection followed by either annulus plication or sliding leaflet plasty has been the gold standard technique to repair PPL and has demonstrated excellent long-term results (3). More recently, an approach favoring leaflet tissue preservation has evolved (4). Over the years, mitral valve repair has been proven to demonstrate significantly better survival than mitral valve replacement (5,6). If mitral valve repair is carried out when the patient is still asymptomatic, surgery is expected to return their life expectancy to normal (7,8). Moreover, valve repair offers equivalent durability to a mechanical prosthesis without the burden of oral anticoagulation. After decades of intensive work, mitral valve repair has become the gold standard to surgically treat patients with mitral regurgitation. This major achievement has been demonstrated in patients operated via median sternotomy. Mitral valve repair has been a dynamic field with constant improvements, one of which has been to try to reduce surgical trauma via the minimally invasive approach. Alain Carpentier was the first to report mitral valve repair through a right thoracotomy with video assistance (9), and was soon followed by similar reports from others (10). Techniques have evolved, instrumentation has improved and today minimally invasive mitral valve repair has become a standard approach. The safety of the operation is similar to that of the sternotomy approach (11) and the long term results are satisfactory (12,13). This video describes the step-by-step repair of a PPL with a “respect” approach performed minimally invasively with total video assistance and no direct vision. The patient is a 42-year-old male patient in sinus rhythm. The patient is asymptomatic. He presented with severe mitral regurgitation, which was discovered during a routine examination. Preoperative echocardiography showed a prolapse of the PPL.