The challenge of Barlow's disease in minimally invasive surgery
Barlow's disease (BD) constitutes one of the most complex forms of mitral degeneration, characterized by excess valvular tissue, annular dilation, and bileaflet prolapse. While reconstructive surgery (MVr) remains the gold standard, its execution via a minimally invasive approach remains a major technical challenge, particularly exposed to the risk of systolic anterior motion (SAM). Faced with this anatomical complexity, which often requires multiple reconstruction techniques, the standardization of procedures is crucial to ensure the reproducibility and safety of clinical results.
This monocentric retrospective study evaluates the medium- and long-term efficacy of a systematized repair technique applied to 55 patients between 2009 and 2021. The specific objective is to validate a surgical protocol based on a precise triptych: resection of the P2 segment of the posterior leaflet, transfer of preserved chordae from P2 to the A2 segment, and implantation of an open semi-rigid ring. The authors test the hypothesis that such a simplified approach, aimed at reducing the excessive height of the posterior leaflet while stabilizing the ring, achieves high operative success rates and prolonged clinical durability, even within this population with complex valvular anatomy.
Design and surgical protocol
This single-center retrospective study included 55 patients suffering from Barlow's disease with severe mitral regurgitation (MR), operated on between September 2009 and February 2021. The surgical approach was based on a standardized minimally invasive technique structured around three key steps:
- Resection of the P2 segment of the posterior leaflet (PML) to reduce its excessive height.
- Transfer of preserved chordae from P2 to the A2 segment of the anterior leaflet.
- Annuloplasty systematically performed by the implantation of a semi-rigid open ring.
The anatomy was confirmed by intraoperative transesophageal echocardiography (TEE). Additional procedures (neochordae or cleft closure) were performed on a case-by-case basis according to saline flush tests. The objective was to simultaneously treat the posterior leaflet excess and the annular instability.
Follow-up and evaluation criteria
The average follow-up was 60.2 ± 37.6 months (range 2 to 127 months), with a completeness of 90.9% (50 patients). A clinical and echocardiographic data update campaign was conducted between 2020 and 2021. The evaluation criteria included:
- Primary objectives: repair success rate and 30-day survival.
- Secondary objectives: overall survival, absence of reoperation and absence of recurrence of grade ≥ 2 MI.
Results: Confirmed long-term hemodynamic stability
Analysis of the 55 patients treated for Barlow's disease with severe mitral regurgitation (MR) highlights high technical efficacy of the standardized approach combining P2 resection, chordal transfer, and annuloplasty with an open semi-rigid ring. The initial success rate of the repair stands at 98.2% (n = 54), with zero mortality (0%) at 30 days.
Follow-up was completed for 50 patients (90.9%), over a mean period of 60.2 ± 37.6 months (ranging from 2 to 127 months). The medium- and long-term results confirm the durability of the technique, particularly for patients who underwent repair during primary surgery.
| Tracking indicator (Primary surgery) | At 5 years | At 8 years |
|---|---|---|
| Overall survival rate | 92.8 % | 88.2 % |
| No reoperation required | 97.3 % | 81.3% |
| Absence of MR recurrence (Grade ≥ 2) | 97.3 % | 81.3% |
From a qualitative and echocardiographic perspective, the observations are particularly notable in the practice:
- Systolic Anterior Motion (SAM): No cases of SAM were detected during transthoracic echocardiographic (TTE) follow-up, validating the strategy of systematic reduction of excessive posterior leaflet (PML) height.
- Valve stability: The rate of freedom from clinically significant mitral regurgitation (grade ≥ 2) is 97.3% at 5 years, falling to 81.3% at 8 years, suggesting excellent intermediate stability before possible late degradation related to complex degenerative pathology.
- Clinical follow-up: Of the initial 55 patients, only 5 were lost to follow-up (9.1%), reinforcing the reliability of the survival data presented.
The total absence of SAM at follow-up is a major result for the practitioner, as this complication is classically dreaded in Barlow's disease surgery due to tissue excess and abnormal annular dynamics.
Clinical analysis and technical reproducibility
The results of this single-center study confirm that Barlow's disease (BD), despite its anatomical complexity, can be effectively treated using a standardized minimally invasive approach. With an initial repair success rate of 98.2% and zero 30-day mortality, the combination of P2 resection, chordal transfer to A2, and semi-rigid ring annuloplasty stands out as a robust strategy. From a haemodynamic perspective, the total absence of systolic anterior motion (SAM) during follow-up is a major finding, as SAM is traditionally a feared complication when correcting mitral tissue excess.
Long-term efficacy is highlighted by an overall survival rate of 88.2% and an absence of reoperation in 81.3% of patients at 8 years. Compared to more heterogeneous techniques often reserved for expert centers, this codified approach appears to simplify the management of posterior leaflet excess and annular instability. It achieves durable results while minimizing the impact of surgical trauma through the minimally invasive approach.
Study limitations and perspectives
The study nevertheless presents inherent limitations due to its retrospective design and its modest cohort of 55 patients. The single-center nature may reflect the specific expertise of the operators, limiting the immediate generalization of the results. Furthermore, 9.1% of patients were lost to follow-up during the average 60-month follow-up period, which may slightly bias the very long-term survival data. Despite these reservations, the stability of the ultrasound results suggests that this technique is a reliable option for the experienced practitioner.
Summary of results
This single-center study conducted on 55 patients demonstrates the effectiveness of a standardized technique combining P2 resection and chordal transfer to A2: the initial success rate reached 98.2% with zero mortality at 30 days. At 8 years, overall survival stands at 88.2% and freedom from reintervention or recurrence of grade ≥ 2 regurgitation remains at 81.3%, with no cases of systolic anterior motion (SAM) reported.
In concrete terms, for the practitioner:
- Standardize your approach: the systematic combination of resection + chordal transfer simplifies the management of complex Barlow valves in minimally invasive surgery.
- Neutralize the risk of SAM: this combined technique effectively reduces the height of the posterior leaflet and stabilizes the annular dynamics over the long term.
- Ensure durability: with more than 81% stable results at 8 years, this protocol offers a reliable and reproducible alternative to more heterogeneous repair techniques.
Technical lexicon of the study
Barlow’s disease (BD): A form of degenerative mitral valve pathology characterized by an excess of valvular tissue causing billowing of the leaflets, chordal elongation, and mitral annular dilatation.
Segment P2: Central part of the posterior mitral leaflet (PML). In this study, the resection of this specific segment is used to reduce the excessive height of the posterior leaflet.
Chordal transfer: Surgical technique consisting of moving preserved native chordae from a resected segment (P2) to a prolapsed or unstable segment (A2) to restore a physiological coaptation line.
Annuloplasty: Mitral valve ring stabilization procedure performed here using a semi-rigid open ring to correct annular dilation and prevent recurrence of regurgitation.
Systolic Anterior Motion (SAM): Potential complication of mitral surgery where the anterior leaflet moves towards the left ventricular outflow tract during systole; the absence of SAM is an indicator of the success of the described technique.
Mitral Regurgitation (MR): Pathological blood reflux from the left ventricle to the left atrium, evaluated in the study on a scale of 0 (absent) to 4 (severe).
Source
- Original title: Mid- to long-term results of minimally invasive repair of Barlow’s disease with posterior leaflet resection and chordal transfer
- Authors: Christina Ballazs, Yukiharu Sugimura, Moritz Benjamin Immohr, Stephan Sixt, Philipp Rellecke, Udo Boeken, Hug Aubin, Hiroyuki Kamiya, Artur Lichtenberg, Payam Akhyari
- Publication: General Thoracic and Cardiovascular Surgery - 2026-06-29
- DOI: https://doi.org/10.1007/s11748-026-02339-y
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