Anterior LeafletĀ
The AL can be involved either in combination with the PL, or separately.
The AL is at the same time more straightforward as the PL, but still a
challenge as long-term results of AL repair have been consistently worse
than those of the PL. Only recently seems the gap to be filled. Given
the important surface of the body of the AL, there could be a need to
support more aggressively the free edge when dealing with a prolapse. We
use 2 techniques, either papillary muscle repositioning, or artificial
chordal support with Gore-Tex 5/0 sutures. Some, such as Tirone David[5] , use multiple loops of Gore-Tex, others as described by
Fred Mohr, use predetermined loops coming from one attachment to the
papillary muscle [6] . The aim, whatever the technique used,
is to correct the prolapse to allow a good coaptation height. Care must
be given to avoid overcorrection, which can decrease leaflet motion and
create excess tension.
The second issue in Barlow of the AL is whether to resect or not.
Carpentier had banned in most cases resection of the AL. As the
pathological process includes excess tissue, it could in some cases be
an option to remove excess tissue, creating a more suitable AL, and
thereby reducing tension on the AL. However, great care must be taken as
a restricted AL may create a disaster and an incompetent valve.
Experience at this level is key, resection, if performed, should be
small, triangular and not create any tension at any cost. Tension on the
PL is not good but could be forgiving, whereas tension on AL, due to an
inappropriate resection, could not.