Surgical Technique for Mitral Valve Prolapse Repair via Median Sternotomy
Incision and Exposure
For MVP repair through the chest via median sternotomy, the lower hemisternotomy approach provides excellent exposure through a 6-8 cm vertical midline incision, allowing direct aortic cannulation and cross-clamping while avoiding the morbidity of full sternotomy. 1
Key Steps for Lower Hemisternotomy:
Make a vertical midline incision extending from the sternal notch to approximately the fourth intercostal space, dividing only the lower sternum while leaving the manubrium intact 1
Open the pericardium vertically and use tonsil clamps to grasp and pull it caudally, improving exposure of the operative field 1
Place three silk sutures on the right side of the pericardium with a cranial skew, sewing them to the caudal half of the skin incision and pulling tightly to expose the heart and pull the aorta caudally into the incision 1
Cannulation Strategy
Place a double purse-string in the ascending aorta and insert a standard ascending aortic cannula, securing it to the skin 1
Perform venous cannulation femorally (either percutaneously or by cutdown), augmented as needed by adding a neck SVC cannula for optimal drainage 1
Insert a root vent into the ascending aorta for de-airing and antegrade cardioplegia delivery 1
Consider retrograde cardioplegia cannula placement according to surgeon preference, particularly if there is any degree of aortic insufficiency 1
Cardiopulmonary Bypass and Myocardial Protection
Initiate CPB with mild hypothermia and use vacuum or kinetic-assist venous drainage to augment cardiac emptying 1
Accomplish aortic occlusion by placing an aortic cross clamp in the standard manner—this is a key advantage of the hemisternotomy approach over peripheral approaches 1
Administer antegrade cardioplegia immediately after cross-clamp placement 1
Flood the operative field with CO2 routinely to assist in de-airing at the end of the procedure 1
Exposure of the Mitral Valve
Develop the interatrial groove and free the right atrium from the left atrium up to the fossa ovalis 1
Open the left atrium widely from the SVC to the oblique fossa under the IVC to facilitate optimal exposure of the mitral valve 1
Do not open the aortopulmonary junction and avoid using a left atrial vent in this approach 1
Repair Techniques for MVP
The specific repair technique depends on which leaflet is prolapsing, but all repairs must address both the leaflet pathology and annular dilation to ensure durability. 2
For Posterior Leaflet Prolapse (Most Common):
Perform quadrangular resection of the prolapsing segment with or without sliding repair, which is the gold standard technique 3, 2
Alternative techniques include: edge-to-edge repair, artificial chordae replacement using expanded polytetrafluoroethylene (e-PTFE) sutures, or chordal transfer 3, 4
For Anterior Leaflet Prolapse:
Use artificial chordae replacement with e-PTFE sutures as the primary technique 3, 4
Chordal transfer from the posterior leaflet can be considered in selected cases 3
For Bileaflet Prolapse (Barlow Disease):
- Employ polytetrafluoroethylene chordal reimplantation for both leaflets, which provides excellent durability 5
Critical Universal Step:
- Perform prosthetic ring annuloplasty in all cases—failure to use a prosthetic annuloplasty significantly jeopardizes repair durability and is associated with higher rates of recurrent MR 2, 6
De-airing and Weaning from CPB
Place temporary epicardial pacing wires on the right ventricle before removing the cross-clamp 1
Accomplish de-airing by filling the heart while closing the atriotomy, using gentle suction on the aortic root vent 1
Allow the heart to recover after clamp removal, then discontinue cardiopulmonary bypass 1
Closure
Place two soft chest drains: one into the oblique sinus and one anteriorly 1
Close the sternotomy with 4 simple wires completely encircling the sternum at the intercostal spaces 1
Place a wire at 45-degree angle at the junction of the second intercostal space to ensure vertical stability and minimize postoperative sternal clicking 1
Alternatively, use a sternal plate to secure the entire sternum 1
Critical Pitfalls to Avoid
Never perform repair without prosthetic annuloplasty—this is the single most important predictor of repair failure, with significantly higher recurrence rates when omitted 2
Avoid inadequate de-airing—the routine use of CO2 flooding is essential to minimize stroke risk 1
Do not proceed with repair if significant mitral annular calcification is present—extensive calcification increases risk of atrioventricular disruption and may require conversion to replacement 1