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Cracking the Code: A Routine, Reproducible, and Standardized Anterior Leaflet Augmentation Technique for Type III Mitral Regurgitation Repair Using Bioresorbable Matrix
Mohammed A. Kashem, Thomas Kelley, Vishnu V. Ambur, James McCarthy, Sheela Pai, Yanfu Shao, Grayson Wheatley, Yoshiya Toyoda, T. Sloane Guy.
Temple University School of Medicine, Philadelphia, PA, USA.

OBJECTIVE: We recently adopted a simple technique to treat Carpentier Type III mitral insufficiency (MR) using routine anterior leaflet augmentation with CorMatrix Extracellular Matrix (ECM) in robotic mitral valve surgery with good short-term results. The primary goal of our simplified technique is to dramatically improve leaflet coaptation. We believe the ECM also preserves the mobility of the anterior leaflet which is important for leaflet function.
METHODS: During December-2011 to November-2013, we performed totally endoscopic robotic mitral valve repair in 20 patients. Flexible bands were used in all cases with sizes of 27.9±2.2mm. Our simplified technique involves detachment of the anterior leaflet at its base from commissure to commissure (allowing the native leaflet to fall posteriorly toward the posterior leaflet) and placement of a large ECM patch into the defect. An annuloplasty sizer is used to select a band based on the inter-trigonal distance and is also used as an exact template to fashion the ECM patch.
RESULTS: Mean age was 58.5±3.0 years. EF was 48.6±3.4%. Pre-op regurgitation was severe in all cases. There was no in-hospital mortality. Bypass time was 132±8 minutes and 96±4 minutes cross-clamp time. 2 cases needed blood transfusion and 1 patient needed additional tricuspid repair. Median length of stay was 7±0.7 days. Post-op echocardiography demonstrated a 50±4% EF and all patients were free of MR at the end of surgery on follow-up one month later.
CONCLUSIONS: The routine use of this simple technique of anterior leaflet augmentation with ECM for Type III MR produced consistent and excellent short-term results by dramatically improving leaflet coaptation. Having struggled to repair these valves in the past, we feel we have "cracked the code" on Type III MR.

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