Endoscopic secondary chordae transfer and edge-to-edge repair for the treatment of asymmetric anterior leaflet prolapse

Anterior leaflet prolapse remains a challenging lesion in mitral valve repair, particularly in the presence of asymmetric degenerative disease. We present the case of a 59-year-old patient with severe mitral regurgitation due to asymmetric anterior leaflet prolapse in the setting of Barlow's disease, treated through a totally endoscopic right minithoracotomy. Intraoperative valve analysis demonstrated prolapse of the A2M2 and A3 segments with elongated secondary chordae. Mitral valve repair was performed using secondary chordae transfer, followed by asymmetric edge-to-edge repair at the A2-P2 scallops and ring annuloplasty. Intraoperative assessment showed satisfactory leaflet coaptation with trivial residual regurgitation. Postoperative echocardiography confirmed the absence of residual mitral regurgitation and no evidence of clinically significant mitral stenosis. This report describes the technical aspects of endoscopic secondary chordae transfer combined with asymmetric edge-to-edge repair and ring annuloplasty for the treatment of asymmetric anterior leaflet prolapse, demonstrating the feasibility of this repair strategy in a complex mitral valve anatomy.