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Ann Thorac Surg 2004;78:1879-1880
© 2004 The Society of Thoracic Surgeons

Correspondence

Repair of Barlow's Mitral Valve: To Do or Not to Do

Keita Tanaka, MD, Makoto Takeda, MD

Division of Cardiovascular Surgery, Teikyo University School of Medicine, Ichihara Hospital, 3426-3, Anesaki, Ichihara City, Chiba 299-0111, Japan

kyky-tanaka{at}mvc.biglobe.ne.jp

To the Editor:

We read with interest the article by Fasol and Mahdjoobian [1] on a surgical technique to repair mitral valve billowing and prolapse (Barlow's disease). In their study, 37 patients with Barlow's disease underwent mitral valve repair, including triangular resection of the anterior leaflet, with excellent midterm results. We agree with the concept of Fasol and Joubert-Hübner [2] that triangular resection of the anterior leaflet is a safe and simple technique for this disease because the prolapse of the anterior leaflet is thought to be due mainly to a markedly redundant leaflet with excess tissue. Their technique seems more reasonable than other procedures such as extensive use of artificial chordae or transposition of the posterior chordae.

We [3] reported good results in a "typical" patient who required triangular resection of the anterior mitral leaflet, and the patient did well (New York Heart Association functional class I–II). However, 7 years after operation, mild mitral regurgitation was identified during an annual follow-up echocardiographic evaluation and gradually progressed to moderate regurgitation in association with left ventricular dilatation by 8 years postoperatively.

As mentioned by Fasol and Mahdjoobian, the characteristic features of marked billowing, mainly of the anterior leaflets, and a substantial amount of excess tissue can be useful to distinguish a Barlow's mitral valve from other forms of mitral valve disease. The complex and worrisome appearance at operation makes surgeons uneasy about the possibilities and limitations of repair. Moreover, the exact histopathology of the Barlow valve remains uncertain. According to Fornes and co-workers [4], a Barlow valve has histological patterns similar to those of Marfan's syndrome. In terms of quantitative histology, that means that more collagen alterations and myxoid infiltration are observed in the leaflet in Barlow's disease than in fibroelastic deficiency, whereas only small differences are evident in qualitative histology. The resulting fragility of the leaflet and the hemodynamic stress on it appear to lead to redundancy and stretching of the mitral valve. Taking this idea into consideration, we recently speculated that the remaining valve tissue would, in turn, also exhibit signs of redundancy, thus leading to recurrent mitral regurgitation.

Repair of Barlow's mitral valve is challenging, and it would be desirable to know the long-term results of repair using the technique reported by Fasol and Mahdjoobian.

References

  1. Fasol R, Mahdjoobian K. Repair of mitral valve billowing and prolapse (Barlow): the surgical technique. Ann Thorac Surg. 2002;74:602–605[Abstract/Free Full Text]
  2. Fasol R, Joubert-Hübner E. Triangular resection of the anterior leaflet for repair of the mitral valve. Ann Thorac Surg. 2001;71:381–383[Abstract/Free Full Text]
  3. Tanaka K, Furuse A, Kotsuka Y, et al. Mitral valve repair with extensive resection of the anterior leaflet for regurgitation due to Barlow's disease: Report of a case. Jpn Heart J. 1997;38:865–868[Medline]
  4. Fornes P, Heudes D, Fuzellier JF, Tixier D, Bruneval P, Carpentier A. Correlation between clinical and histologic patterns of degenerative mitral valve insufficiency: a histomorphometric study of 130 excised segments. Cardiovasc Pathol. 1999;8:81–92[Medline]




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