Edge-to-edge mitral valve repair for bileaflet prolapse in Barlow disease

Barlow disease with bileaflet prolapse represents one of the most challenging lesions in degenerative mitral valve surgery. Multiple prolapsing segments, excess leaflet tissue, elongated chordae and annular dilatation often coexist, requiring a comprehensive repair strategy. The edge-to-edge technique, first introduced in 1991, provides a simple and reproducible method to restore leaflet coaptation in this complex setting. By approximating the free edges of the anterior and posterior leaflets at the site of regurgitation, a double-orifice mitral valve is created. This single manoeuvre effectively addresses bileaflet prolapse, reduces leaflet height, forces coaptation, restricts excessive leaflet motion and prevents systolic anterior motion of the anterior leaflet. A concomitant ring annuloplasty is strongly recommended to remodel the dilated annulus, stabilize the repair and ensure long-term durability. This video tutorial presents the key surgical steps of the double-orifice edge-to-edge repair combined with annuloplasty for the treatment of severe mitral regurgitation caused by bileaflet prolapse in Barlow disease. The procedure is performed through a anterolateral minithoracotomy at the fourth intercostal space under video assistance with peripherical cardiopulmonary bypass and cardioplegic arrest. Technical tips for patient selection, suture placement, leaflet assessment, avoidance of mitral stenosis and intraoperative competence testing are provided.