1. Recent Developments and Evolving Techniques of Mitral Valve Reconstruction 
Frank C Spencer, Aubrey C Galloway, Eugene A Grossi, Greg H Ribakove, Julie Delianides, F.Gregory Baumann, Stephen B Colvin 
The Annals of Thoracic Surgery 
Volume 65, Issue 2, Pages (February 1998)
DOI: /S (97)

2. Fig. 1
Figs. 1–3 are illustrated from the surgeon’s perspective, with the patient’s head to the left. The first incision follows the dotted line from the mid-lateral wall of the right atrium over the right atrial appendage to the superior end of the interatrial septum, with care taken to leave a margin of atrial tissue toward the atrioventricular groove to facilitate closure. The solid arrow on the dome of the left atrium indicates the course of the left atrial incision, which is made after the septal incision (Fig. 2) joins the right atrial incision. Depending on the size of the right atrium, the right atrial incision can begin at any point along the line indicated. When the atrium is large, the incision can be confined to the trabecular portion of the atrium. (Reprinted with permission from Smith CR. Septal-superior exposure of the mitral valve. The transplant approach. J Thorac Cardiovasc Surg 1992;103:623–8.)
The Annals of Thoracic Surgery  , DOI: ( /S (97) )

3. Fig. 2
The dotted line indicates the course of the septal incision, which is made after the right atrium is opened (Fig. 1), beginning in the foramen ovale. The incision should be placed closer to the posterior limbus, to give the coronary sinus and posteromedial corner of the mitral annulus a wider protective margin of anterior septal tissue. At a point roughly opposite the orifice of the right superior pulmonary vein, the incision deviates anteromedially through the anterior limbus and the thick muscle of the superior septum to meet the right atrial incision (Fig. 1). In most patients the sinus node artery is divided where it lies in the muscle of the superior septum (visible in Fig. 3). (Reprinted with permission from Smith CR. Septal-superior exposure of the mitral valve. The transplant approach. J Thorac Cardiovasc Surg 1992;103:623–8.)
The Annals of Thoracic Surgery  , DOI: ( /S (97) )

4. Fig. 3
The left atrium is opened beginning at the junction of the septal and right atrial incisions and is extended across the left atrial dome toward the base of the left atrial appendage. A margin of atrial tissue must remain on the side of the atrioventricular groove to allow closure. The divided ends of the sinus node artery are illustrated in the muscle of the superior septum. (Reprinted with permission from Smith CR. Septal-superior exposure of the mitral valve. The transplant approach. J Thorac Cardiovasc Surg 1992;103:623–8.)
The Annals of Thoracic Surgery  , DOI: ( /S (97) )

5. Fig. 4 Prolapsing anterior mitral valve leaflet.
The Annals of Thoracic Surgery  , DOI: ( /S (97) )

6. Fig. 5 Triangular resection of prolapsing anterior mitral leaflet.
The Annals of Thoracic Surgery  , DOI: ( /S (97) )

7. Fig. 6
Suturing of defect in anterior mitral leaflet after triangular resection.
The Annals of Thoracic Surgery  , DOI: ( /S (97) )

8. Fig. 7
Defect in prolapsing mural mitral valve leaflet after quadrangular resection of leaflet. Instead of plicating the annulus, point A on the leaflet is moved toward point a on the annulus and point B on the leaflet is moved toward point b on the annulus, as shown in Fig. 8.
The Annals of Thoracic Surgery  , DOI: ( /S (97) )

9. Fig. 8
Folding of margins of resected mural leaflet toward the annulus.
The Annals of Thoracic Surgery  , DOI: ( /S (97) )

10. Fig. 9
Suturing of resected margins of mural leaflet to the mitral annulus and to each other.
The Annals of Thoracic Surgery  , DOI: ( /S (97) )