1. Repair of mitral valve billowing and prolapse (Barlow): the surgical technique 
Roland Fasol, MD, Katja Mahdjoobian, MD 
The Annals of Thoracic Surgery 
Volume 74, Issue 2, Pages (August 2002)
DOI: /S (02)

2. Fig 1
(A) Schematic drawing of the complete resection of the middle scallop of the posterior leaflet (P2), the triangular resection of the anterior leaflet (A2) and partial detachment of the remaining posterior scallops (P1 and P3). A portion of the annulus is plicated (point x), a combined sliding leaflet and folding plasty with both of the remaining posterior scallops (P1 and P3) performed with a running Péters suture, by reattaching the scallops in a way that point y of the leaflet meets point y of the annulus, and point x of the leaflet meets point x of the annulus. The free edges of the anterior and the posterior leaflets (between points x and z) are reapproximated with a running Péters suture. (B) Schematic drawing showing the reconstructed valve. A prosthetic annuloplasty ring is implanted to reinforce the repair.
The Annals of Thoracic Surgery  , DOI: ( /S (02) )

3. Fig 2
(A) Intraoperative view of a typical “Barlow valve,” showing enormous hood-like bulging with significant excess tissue of all segments of the mitral valve. Specifically, the scallops A2 and P2 show a marked billowing and prolapse. (B) Complete resection of the middle scallop of the posterior leaflet (P2) and partial detachment of the remaining posterior scallops (P1 and P3) to allow a sliding leaflet as well as a folding plasty of the remaining segments P1 and P3. The points x, y, and z mark the “endpoints” of the leaflet reconstruction. (C) A portion of the annulus is plicated (point x), a combined sliding leaflet and folding plasty with both of the remaining posterior scallops (P1 and P3) performed with a running Péters suture, by reattaching the scallops in such a way that point y of the leaflet meets point y of the annulus, and point x of the leaflet meets point x of the annulus. The free edges of the posterior leaflets (between points x and z) are also reapproximated with a running 5-0 Péter’s suture. (D) Intraoperative view of the reconstructed posterior leaflet. After complete resection of the scallop P2, the remaining lateral scallops P1 and P3 form the “new” posterior mitral leaflet. Sutures for the prosthetic annuloplasty ring have been put through the annulus before reattaching the leaflets into the annulus. (E) A triangular resection of the anterior leaflet (A2) is performed, the size and extent of the resection carefully matched to the extent of bulging. Free edges of the remaining anterior scallopsA1 and A3 are reapproximated with a running 5-0 Péter’s suture. (F) Intraoperative view of the reconstructed mitral valve. A prosthetic annuloplasty ring is implanted to reinforce the repair.
The Annals of Thoracic Surgery  , DOI: ( /S (02) )

4. Fig 3
Schematic drawing of a “Barlow valve” indicating hood-like bulging of the anterior leaflet. The bulging of the anterior valve leaflet is “height”-corrected (Δh) by a triangular resection of the segment A2, which also causes a subsequent functional correction of otherwise elongated chordae tendinae. (Ch = chordae tendineae; P = papillary muscle).
The Annals of Thoracic Surgery  , DOI: ( /S (02) )