Posterior Leaflet Overlay Patch Reinforcement for Mitral Valve Posterior Tethering: The Elbow Patch Repair

H. Kim¹, J. Yoo^2
1Ewha Womans University Seoul Hospital, Seoul, Seoul-t'ukpyolsi ²Asan Medical Center, Seoul, Seoul-t'ukpyolsi

Please explain the educational or technical point that this video addresses.: Mitral valve repair is complicated by a restrictive posterior mitral valve leaflet. This condition, often seen in ischemic myocardial disease, idiopathic dilated cardiomyopathy, and end-stage heart disease, falls under Carpentier’s functional classification type IIIb, characterized by pure systolic restricted leaflet motion with preserved leaflet pliability. Recent insights into atrial functional mitral regurgitation have shown that advanced left atrial remodeling draws the posterior mitral annulus towards the basal posterior wall of the left ventricle, causing atriogenic leaflet tethering and a relative tissue shortage. To address the issue of systolic restricted leaflet motion with tissue paucity, the "elbow patch repair" technique, which reinforces the posterior mitral valve leaflet with an autologous pericardium overlay patch, has proven to be an effective solution by restoring an adequate coaptation surface.

Please provide a 250 word summary of the surgical video being submitted.: This surgical video demonstrates posterior leaflet overlay patch reinforcement using autologous pericardium: the "elbow patch repair"
A 65-year-old male patient presented with chronic persistent atrial fibrillation and severe mitral regurgitation. Initial evaluation with transthoracic echocardiography revealed a dilated left atrium and mitral annulus with preserved ejection fraction heart failure, which likely induced atrial functional mitral regurgitation, marked by posterior leaflet tethering and anterior leaflet prolapse. An undersized annuloplasty with a complete ring (CG future band 34mm, Medtronic, MN, United States) was performed for annular remodeling, accompanied by the formation of two neochordae on the anterior leaflet to address the anterior prolapse. Despite these interventions, the restrictive posterior mitral valve leaflet tissue due to annular dilatation suggested that a sufficient coaptation area was not secured. To address the insufficiency, an “elbow patch repair” involving the reinforcement of the posterior leaflet with an autologous pericardium overlay patch was employed to secure the coaptation surface. Postoperative echocardiography showed no remnant MR, a mitral valve(MV) area of 2.6 cm², and a transmitral pressure gradient of 10/2 mmHg.