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:
1) to reduce the amount of stiff, irregular, non-pliable excess tissue,
2) to reduce the surface of the leaflet, which is the major component of excess tension,
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 [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?