Fleur de Lys Repair of Posterior Mitral Valve Leaflet

(A) Posterior leaflet with prolapsing middle scallop. (B) Primary chords have ruptured. (C) Note the thickening in presence of secondary chords spreading on either side of the prolapsing belly of middle scallop.

(A) Conceptually each scallop can be visualized as a Fleur de Lys. The resection of the abnormal middle component of the middle scallop is curvilinear and the obverse to the middle Fleur de Lys frond. In actuality, the resection does not come to a point but is really more trumpet-shaped. (B) The Fleur de Lys concept does give the operator the sense of the curves rather than straight-line V resection to be performed as well as the areas of more normal tissue as represented by the right and left fronds.

(A) The resection is relatively conservative and does not extend completely to the annulus. (B) An initial suture starts the in-folding toward the base. Horizontal mattress suture at the leading edge is also placed so as to cause in-folding for creation of the pseudo-commissure. (C) Sequential simple stitches then are placed between the first and last sutures to complete the repair. (C1) The suture, as it passes through the leaflets for the repair, incorporates a tucked or folded chordal element. This effects chordal shortening at the leaflet level and also reinforces the leaflet repair. (D) The basal suture is tied.

(A) On the annulus at the base of the leaflet repair, a pledgeted mattress suture is placed to compress the annulus and thereby reduce stress on the leaflet repair. (B) Additional sutures are placed in between the previously placed sutures. These are absorbable and serve to strengthen and cause a more secure healing of the leaflet repair. These “in-betweens” are fine absorbable sutures. (C) The ring is positioned with the circumferential shortening being performed at the commissures and at the level of the annular narrowing at the base of the middle scallop repair. The remainder of the horizontal mattress annular sutures are placed normal to the arc of the circumference.

(A) Manual distraction enlarges the horseshoe opening. (B) Upward pressure by the first fingers creates the saddle shape. (C) This demonstrates the sinus aortic bulge. (D) The anterior leaflet and its annular coalescence with the aortic valve can move and expand unimpeded by the ring annulus repair.