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\begin{document}

\title{Respect or resect in Barlow disease.}



\author[1]{Gilles Dreyfus}%
\author[2]{Filip Dulguerov}%
\affil[1]{Institut Mutualiste Montsouris}%
\affil[2]{CHUV}%


\vspace{-1em}



  
  \date{May 21, 2024}


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\let\center\flushleft
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\maketitle
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\selectlanguage{english}
\begin{abstract}
Mitral regurgitation in Barlow disease may still be challenging to be
repaired . Most often it involves the posterior leaflet . Many
techniques and concepts are currently available ; the main goal being to
restore a good surface of coaptation . Basic principles such a thorough
analysis is still required whatever the approach to assess excess tissue
height , width and prolapse . Nowadays it seems that two different ways
of treating mitral prolapse coexist : the non resection one and the
resection one .Both will be discussed and analysed . Similarly the use
of artificial chordae seem to have a preponderant role to support the
free edge and correct a prolapse . Native secondary chord transfer are
easy and reliable but seem abandoned by many . Anterior leaflet prolapse
is also dealt with and fewer options are available to address this
leaflet . Then commissural prolapse is mentioned . It is an important
area of the valve which should deserve better treatment than
commissuroplasty . Finally a special entity will be described ; mitro
annular disjonction . The approach is not or no longer an issue as only
good long term results are important in an era where per cutaneous
therapy is the only non invasive technique .%
\end{abstract}%



\sloppy


\textbf{Respect or Resect in Barlow disease}

Gilles D Dreyfus, MD, PhD, Institut Mutualiste Montsouris, Paris, France

Filip Dulguerov, MD, H\selectlanguage{ngerman}ôpitaux Universitaires de Genève, Genève,
Switzerland

\textbf{Introduction}

Mitral valve repair (MVr) is recognized as being the best treatment for
severe mitral regurgitation, especially when
degenerative\textbf{{[}1{]}} . Since the beginning of MVr, many options
have been advocated. From the wide quadrangular resection by Carpentier
to the triangular resection by the Mayo Clinic. Overall, the general
trend is to resect, but less than previously - to avoid tension and not
to plicate the annulus. Then came the option of not resecting at all, as
opposed to resecting. It is sometimes obvious that in dystrophic mitral
regurgitation with a thin ruptured chord no resection can be a good
option as there is no excess tissue. On the contrary, a typical Barlow
shows excess tissue, and even coexisting areas with prolapsed tissue and
billowing tissue with no prolapse. MVr should not follow any dogma, but
just make sense. The aim of any repair is to achieve a good surface of
coaptation, with the smoothest surface possible. Coaptation height
should be assessed in every repair at the end after weaning from by-pass
as it is a key issue for long term durability.

«~Resect or respect~» concepts are not in opposition: they just do not
apply to the same patients. Those who favor the ``respect rather than
resect'' do resect whenever needed, and those who resect do ``resect
with respect'' and do not plicate the annulus , which in the real world
does not oppose as much as one would believe, one technique to the
other. It seems also fair to mention that there are few long-term
results with longitudinal follow up beyond 10 years, and that those
published refer if not all to the resection philosophy.

\textbf{The Resect with Respect Concept}

Resection depends on the lesions found at echocardiogram and then during
surgery. Barlow etiology concerns usually younger patients, with some
various degrees of excess tissue and sometimes some annular and leaflet
stiffening or calcification. The Posterior Leaflet (PL) is most
frequently involved in around 65 to 75\% of the cases; both leaflets, PL
and Anterior Leaflet (AL), in 10 to 15\% of the cases and the remaining
involves the AL alone. The resection may apply to the PL most frequently
but can be discussed in the AL as well.

Resection has many aims:

\textbf{1)} to reduce the amount of stiff, irregular, non-pliable excess
tissue,

\textbf{2)} to reduce the surface of the leaflet, which is the major
component of excess tension,

\textbf{3)} to eradicate annular and/or leaflet calcifications.

As already mentioned previously, the annulus is not plicated and
subsequently resecting does not imply in any way the use of smaller
rings as opposed to the non-resection strategy; the size of the
annuloplasty ring being measured accordingly to the surface of the AL,
not involved in the resection . Resection is sometimes mentioned, as a
break off all ties strategy, but provided there has been a proper
teaching and experience with this option, there are no such concerns;
moreover it would look strange to favor no resection only to avoid a
secondary lack of tissue! We have published elsewhere
\textbf{{[}1{]}}that when facing a Barlow, there are 3 questions to be
answered: is there any excess height, is there any excess width, and,
finally, where is the prolapse located?

\textbf{Posterior Leaflet}

\selectlanguage{greek}\textbf{Excess height (figure1 α 2)}\selectlanguage{english}

Excess height is the most common lesion of P2 and sometimes of P1 and
P3. In a normal Mitral Valve (MV), P2 is only slightly higher than P1
and P3, if not at the same height. The excess height~going along with
billowing is the result of the pathological process. The good closure
line should not be in the middle of the mitral orifice but divided at
2/3 for the anterior leaflet and 1/3 for the posterior leaflet, if not
3/4 and 1/4, and it should be regular. To achieve these goals, one has
to reduce P2 height. The aim is to reduce the height by performing a
resection of P2. Resection location takes place at the level of the
pathological process, either at the free edge when chordae are ruptured
or elongated, or at the annular level in case of billowing without
prolapse or in case of annular calcification . Resection can be of
various shapes: it can be triangular; it can be at the free edge
transversally; it can follow a resection close to the annulus at the
hinge of the leaflet which is then reattached after a regular or an
irregular resection creating a sort of sliding plasty, or it can be very
symmetrical using a resection and a double sliding such as in the
``butterfly technique''. By doing a transverse resection (wrongly called
``hair cut technique'' \textbf{{[}2{]}} ), only the excess height is
being addressed. Some techniques, such as the sliding plasties or the
butterfly technique \textbf{{[}3{]}} , can address both the excess
height and some excess width at the same time. Similarly, the triangular
resection may, in limited and favorable pathologies, take care of both
the excess height and the excess width.

If the free edge does not show any pathological process (no prolapse, no
elongated or ruptured chordae but most often in such instances a
billowing of P2), we then address the issue of leaflet height by
reducing it at the annular level. We detach the leaflet from the
annulus, resect some leaflet tissue and re attach the leaflet to the
annulus without any transverse displacement. This is what we call a
``false sliding''. We also use this maneuver in case of a pathological
process at the annular level such as a calcified annulus which requires
decalcification \textbf{(Figure 2)} .

\textbf{Excess width (figure 3)}

Excess width was emphasized in our 2006 publication \textbf{{[}2{]}}when
we advocated to use small triangular resections to treat excess width;
the concept was later also reinforced by Perier \textbf{{[}4{]}} . As
stated, the purpose of addressing excess width is to create a smooth
surface of coaptation, by eliminating the folding of thickened tissue.
In his discussion section, Perier confessed that up to 35 \% of cases
required triangular resection due to excess tissue in
width\textbf{{[}4{]}} . In comparison, we usually resect the width in
most of patients (around 75\%). When the rough zone has been resected,
the transverse excess tissue becomes obvious as the leaflet tissue folds
naturally, at the level of excess width . If the rough zone is left
intact, any billowing tissue has both excess height and excess width.
Resection is most often triangular with the base of the triangle being
at the free edge. Should resection reach the annulus or not? Most reach
the annulus and some stop in the middle; none has proven to be superior
one to the other. How can a resection be assessed to avoid excess
tension? In our opinion, the best criterion indicating that there is not
too much resection, is to be able to apply the entire posterior leaflet
without any tension along the posterior wall of the left ventricle (a
physiological MV never shows such excess tissue as seen in a Barlow).

\textbf{Prolapse treatment: Gore-Tex versus native chordae (figure 4)}

After having resected excess tissue, the new P2 leaflet requires the
free edge to be supported, treating thereby the prolapse component
either with native chordal transfer or with artificial chordae. Several
patients require both. First of all, secondary chordae are often, at the
adequate length, when compared to the reference point. The reference
point is sometimes not obvious , but rarely and sits at the level of P1
, close to the indentation in between P1 and P2 . Transferring and
reattaching them relieves the burden of finding the adequate length
which remains an issue when using multiple artificial chordae. We detach
the secondary chordae along with some tissue of the ventricular aspect
of the leaflet, allowing with a mattress suture of 5/0 monofilament to
reattach it at the free edge level. Most often 2 or 3 transferred
chordae are sufficient to support the free edge adequately. So far, we
never saw such reimplanted chord failing neither at an early stage nor
in a later reoperation for another purpose. The number of native or
artificial chordae used per patient, in our experience, is rather small
when compared to others (mean = 2, range: 1-4; \textbf{{[}1{]}} ). The
reason that our use of chordae, either artificial or native, is limited,
is related to the fact that we address only the prolapse and do not
intend to address other issues such as excess tissue at the same time.

In our experience the use of native chordae is always preferable to
artificial substitutes, however artificial neo chordae are indicated
whenever adequate native chordae are not available. When using
artificial chordae we take great care not to cross P2 midline , chordae
arising from the anterior papillary muscle remain at the level of P1 and
at the lateral aspect of P2 , whereas those arising from the posterior
papillary muscle remain at the level of P3 or at the postero medial
aspect of P2 . We use routinely an interlocked suture to avoid the
slippery effect of the artificial chordae and tie them under the tension
of the water test to avoid any over correction This being said,
others\textbf{{[}5,6{]}} use Gore-Tex chords on a regular basis, whether
or not associated with resection techniques, and provide good long-term
results \textbf{{[}5{]}} .

\textbf{Anterior Leaflet~}

The AL can be involved either in combination with the PL, or separately.
The AL is at the same time more straightforward as the PL, but still a
challenge as long-term results of AL repair have been consistently worse
than those of the PL. Only recently seems the gap to be filled. Given
the important surface of the body of the AL, there could be a need to
support more aggressively the free edge when dealing with a prolapse. We
use 2 techniques, either papillary muscle repositioning, or artificial
chordal support with Gore-Tex 5/0 sutures. Some, such as Tirone
David\textbf{{[}5{]}} , use multiple loops of Gore-Tex, others as
described by Fred Mohr, use predetermined loops coming from one
attachment to the papillary muscle \textbf{{[}6{]}} . The aim, whatever
the technique used, is to correct the prolapse to allow a good
coaptation height. Care must be given to avoid overcorrection, which can
decrease leaflet motion and create excess tension.

The second issue in Barlow of the AL is whether to resect or not.
Carpentier had banned in most cases resection of the AL. As the
pathological process includes excess tissue, it could in some cases be
an option to remove excess tissue, creating a more suitable AL, and
thereby reducing tension on the AL. However, great care must be taken as
a restricted AL may create a disaster and an incompetent valve.
Experience at this level is key, resection, if performed, should be
small, triangular and not create any tension at any cost. Tension on the
PL is not good but could be forgiving, whereas tension on AL, due to an
inappropriate resection, could not.

\textbf{Commissural area}

The anterior and the posterior commissures are not at all alike. The
anterior commissure is rarely involved, mostly as it is well supported
by the trigone. On the contrary, the Posterior Commissure (PC) is free
of any support and most likely its involvement is underestimated. There
are obvious prolapses of the PC, and there are billowing which may seem
innocuous but may be favoring with time a recurrent regurgitation due to
its weakness.

Given that this area is all supported by many chordae arising from the
posterior papillary muscle displacing downwards the adequate head, may
correct very easily any posterior commissural prolapse. We have
described this idea as a new surgical technique that we called Papillary
Muscle Repositioning (PMR) in 2006 \textbf{{[}7{]}.} In our experience
it is the method of choice to treat AL and PC prolapse, due to elongated
chordae and irrespectively of the location of the lesion, with excellent
clinical and echocardiographic long-term results.

Alternatively, artificial chordae cannot easily be used as it is the
area of the valve which has as the greatest number of chordae. Many
surgeons, referring to Carpentier use what they call a commissural
plasty or ``commissuroplasty ``which is a complete closure of the
posterior commissure, suturing together A3 to P3. This technique is very
fast and simple. It does not promote any coaptation. Whether it is
efficient in terms of durability remains to be confirmed. As a comment,
Carpentier never closed the PC in Barlows , but described a similar
technique in rheumatic patients, for whom the PC required to be
reconstructed after complete decalcification reaching the annulus . The
PC area was reconstructed by using inverted single sutures for 6 to 10
mm, thereby recreating the PC.

\textbf{Annuloplasty}

At the last stage of MVr, a conventional water test is always performed
without annuloplasty ring and sutures. If the water test is not perfect,
we seek for remaining problems, but we never rely on the annuloplasty to
eradicate a residual leak.

We use annuloplasty rings in all patients (but alternatively, bands from
one trigone to the other could be employed) measuring the size according
to the unfolded anterior leaflet and always using the upper size in case
of a doubt. In our view, an annuloplasty is mandatory to reshape the
annulus and to decrease the tension on it. It should be stressed that
annuloplasty does not promote coaptation. Coaptation should be achieved
before any annuloplasty.

Finally, there are more and more concerns about the use of rings that
are too small, creating dynamic mitral stenosis. In Barlow, rings and
bands should be at least the same size as the anterior leaflet and
probably slightly bigger.

\textbf{Mitro annular disjunction}

Mitro annular disjunction is an entity on its own which combines:

\textbf{1)} symmetrical end systolic regurgitation,

\textbf{2)} excess tissue of both anterior and posterior leaflets,

\textbf{3)} end systolic excursion of P2 out of the plane of the
annulus, and

\textbf{4)} a very specific kink of the base of the Left Ventricle (LV)
due to a lack of ventricular muscle reaching the MV annulus.

This entity is more frequently identified as before, and the two main
features are, 1)the kink of the base of the LV just below the PL in end
systole, and 2) the features of the regurgitant jet which is all along
the closure line and centrally directed. Surgery is sometimes required
despite mild to moderate regurgitation. Its syndrome can also be
accompanied by malignant ventricular arrythmias which may explain sudden
deaths in relation with ventricular fibrillation. Such patients in their
work up should undergo a Gadolinium MRI, searching for a ventricular
scar despite normal coronary anatomy and even more specifically a
papillary muscle scar. Surgery may eliminate the arrhythmic episodes but
not in all cases. Some have suggested cryoablation of the papillary
muscle and in other patients a permanent AICD implantation may be
indicated.

In some cases, but not all, a simple annuloplasty may be sufficient as
it suppresses end systolic motion and the kink of the base of the LV,
which in turn eradicates the regurgitation, by bringing back both
leaflets into the LV cavity in systole. In some cases, a true repair is
required in order to reduce P2 height and avoid a post-operative SAM

Alfieri is currently using in such cases a modified Alfieri stitch,
which is a complete running suture between A2and P2 in the body of the
leaflets, leaving 2 orifices at the level of A1-P1 and A3-P3, always
associated to a complete ring annuloplasty.

\textbf{Conclusion}

The aims of each and every MVr, whatever the technique used, must be to
restore a coaptation height between A2 and P2 of 8 to 10 mm, to restore
coaptation depth, to respect leaflet mobility and to achieve a
harmonious 2/3 -- 1/3 (even 3/4 -- 1/4) closure line.

The concept of \selectlanguage{ngerman}«~respect without resection~» sounds very appealing as it
is easy and fast to perform. Therefore, it has gained further
popularity, especially with minimally invasive MV surgery approach .

Our personal opinion is that the «~respect~» technique's major drawback
is related to the tension applied to the chordae as keeping all the
pathological tissue necessarily increases the tension on them. In turn,
this leads to early failures due to recurrent prolapse with or without
chordal rupture or tear of the leaflet.

The coaptation height (which is measured in end systole in between A2
and P2) is never equal to the height of P2. This technique brings an
asymmetrical coaptation with the tip of A2, and, therefore, a false
sense of security given that one could believe that «~the reserve of
coaptation~» of the new MV is very high.

Another issue with the concept of non-resection is the mandatory pulling
of P2 downwards in the left ventricle, so that the indentations become
wide open and require closure, as P2 is not at the same level as P1 and
P3 anymore. As opposed to this technique the resection technique never
open the indentations and their closure is not necessary .

Finally, the ultimate goal of all mitral repair strategies should be to
decrease excess tension at each and every level of the mitral apparatus.
We therefore believe that oversimplification applicable to all mitral
repairs such as artificial chordae and ring annuloplasty is quite
appealing but surely not realistic. Moreover, patients need to do well,
early and later, in order to keep mitral repair as the gold standard
{[}4{]}. Little is known about the long-term results of those advocating
such simplification. Major recognized surgical teams in the world,
showing results with a follow up of 10 years or more and with
longitudinal echocardiographic data, use a variety of resection
techniques as a key point in the treatment of most degenerative MV
diseases (Cleveland Clinic, Mayo Clinic, Toronto General Hospital, Mount
Sinai,\ldots{}\textbf{{[}8,9,10,11,12,13,14{]}} ), as we also do.

\textbf{Figures}

\textbf{Figure 1} : Surgical strategy used in case of a pathological
process at the free edge\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image1/image1}

\end{center}
\end{figure}

\textbf{Figure 2} : Surgical strategy used in case of a pathological
process at the annular level\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image2/image2}

\end{center}
\end{figure}

\textbf{Figure 3} : Surgical strategy used in case of excess width\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image3/image3}

\end{center}
\end{figure}

\textbf{Figure 4} : Prolapse treatment\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image4/image4}

\end{center}
\end{figure}

\textbf{References}

\begin{enumerate}
\tightlist
\item
  Dreyfus GD, Dulguerov F, Marcacci C, Haley SR, Gkouma A, Dommerc C ans
  Albert A. ``Respect when you can, resect when you should'': A
  realistic approach to posterior leaflet Mitral Valve Repair. \emph{J
  Thorac Cardiovasc Surg. 2018 Nov;156(5):1856-1866.}
\item
  Dreyfus GD, Corbi P, Rubin S, Aubert S. Posterior leaflet preservation
  in mitral valve prolapse: a new approach to mitral repair. \emph{J
  Heart Valve Dis} . \emph{2006;15:528-30.}
\item
  Asai T. The butterfly technique. \emph{Ann Cardiothorac Surg 2015
  Jul;(4):370-5} .
\item
  Perier P, Hohenberger W, Lakew F, Batz G, Urbanski P, Zacher M, et al.
  Toward a new paradigm for the reconstruction of posterior leaflet
  prolapse: midterm results of the ``respect rather than resect''
  approach. \emph{Ann Thorac Surg} . \emph{2008;86:718-25.}
\item
  David T, David C, Lafreniere-Roula M, Manlhiot C. Long term outcomes
  of chordal replacement with expanded polytetrafluoroethylene sutures
  to repair mitral leaflet prolapse. \emph{J Thorac Cardiovasc Surg.
  2020 Aug;160(2):385-394.}
\item
  Seeburger J, Noack T, Winkfein M, Ender J Mohr FW. Loop
  technique.\emph{Multimed Man Surg.2010 Jan
  1;2010(809):mmcts.2010.004523.}
\item
  Dreyfus G, Neto O, Aubert S. Papillary muscle repositioning for repair
  of the anterior leaflet prolapse caused by chordal elongation. \emph{J
  Thorac Cardiovasc Surg. 2006 Sept;132(3):578-584.}
\item
  Suri RM, Burkhart HM, Schaff HV. A novel method of leaflet
  reconstruction after triangular resection for posterior mitral valve
  prolapse. \emph{Ann Thorac Surg} . \emph{2010; 89;53-6.}
\item
  Carpentier A. Cardiac valve surgery: the ``French correction''.\emph{J
  Thorac Cardiovasc Surg} .\emph{1983;86:323-37.}
\item
  Chemtob RA, Wierup P, Mick S, Gillinov M. Choosing the''Best''
  surgical techniques for mitral valve repair: lessons from the
  literature. \emph{J Card Surg. 2019Aug;34(8):717-727.}
\item
  Gillinov AM, Blackstone EH, Nowicki ER, Slisatkorn W, Al-Dossari G,
  Johnston DR, et al. Valve repair versus valve replacement for
  degenerative mitral valve disease. \emph{J Thorac Cardiovasc Surg}
  .\emph{2008;135:885-93} \textsubscript{.}
\item
  David T\textsuperscript{~},~ David C\textsuperscript{~},~Tsang
  W\textsuperscript{~},~ Lafreniere-Roula M\textsuperscript{~},~
  Manlhiot C. Long-Term Results of Mitral Valve Repair for Regurgitation
  Due to Leaflet Prolapse. \emph{J Am Coll Cardio. 2019Aug 27;74(8):
  1044-1053.}
\item
  Castillo JG, Anyanwu AC, Fuster V, Adams DH. A near 100\%~repair~rate
  for~mitral~valve~prolapse is achievable in a reference center:
  implications for future guidelines. \emph{J Thorac Cardiovasc Surg.
  2012 Aug;144(2):308-12.}
\item
  Braunberger E, Deloche A, Berrebi A. Very long-term results (more than
  20 years) of valve repair with Carpentier's techniques in
  non-rheumatic mitral valve insufficiency. \emph{Circulation. 2001 Sept
  18;104 (12Suppl1): I8-11.}
\end{enumerate}

\selectlanguage{english}
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