Leaflet plication with neochordae implantation: A novel technique for mitral valve repair.

Abstract

Central MessageWe proposed leaflet plication with neochordae implantation as a novel technique for repairing the redundant prolapsing P2 segment.The middle scallop of the posterior leaflet (P2) is the most common site of mitral valve prolapse, and mitral valve repair is superior to mitral valve replacement in the treatment of degenerative mitral valve prolapse.1Suri R.M. Clavel M.A. Schaff H.V. Michelena H.I. Huebner M. Nishimura R.A. et al.Effect of recurrent mitral regurgitation following degenerative mitral valve repair: long-term analysis of competing outcomes.J Am Coll Cardiol. 2016; 67: 488-498Crossref PubMed Scopus (145) Google Scholar Carpentier's method of quadrangular resection with annular plication2Carpentier A. Cardiac valve surgery—the “French correction.”.J Thorac Cardiovasc Surg. 1983; 86: 323-337Abstract Full Text PDF PubMed Google Scholar is considered the gold standard for the treatment of mitral valve prolapse of the posterior leaflet; moreover, this revolutionary nonresection method conducted using artificial chordae has long-term effects comparable with those of leaflet resection.3Perier P. Hohenberger W. Lakew F. Batz G. Urbanski P. Zacher M. et al.Toward a new paradigm for the reconstruction of posterior leaflet prolapse: midterm results of the “respect rather than resect” approach.Ann Thorac Surg. 2008; 86: 718-725Abstract Full Text Full Text PDF PubMed Scopus (183) Google Scholar However, for redundant posterior leaflets, an extra “sliding leaflet plasty”4Perier P. Clausnizer B. Mistarz K. Carpentier “sliding leaflet” technique for repair of the mitral valve: early results.Ann Thorac Surg. 1994; 57: 383-386Abstract Full Text PDF PubMed Scopus (63) Google Scholar or the “butterfly resection technique”5Asai T. The butterfly technique.Ann Cardiothorac Surg. 2015; 4: 370-375PubMed Google Scholar is warranted to decrease the height of the posterior leaflet and avoid systolic anterior motion (SAM). Sliding leaflet plasty and butterfly resection are somewhat complicated and time-consuming. Herein, we introduce a novel, simplified mitral valve repair technique involving leaflet plication using artificial chordae implantation for the redundant prolapsing P2 segment.Surgical TechniqueThe technique was performed in 10 patients, and all of them provided written informed consent. A minimally invasive approach was employed, and cardiopulmonary bypass was established by femoral arterial and venous cannulation. A right minithoracotomy with a 5-cm-long incision was performed over the fourth intercostal space. After we temporarily arrested the heart using antegrade cold blood cardioplegia, the left atrium was accessed via the interatrial groove. The prolapsed P2 was gently lifted with forceps; then, each mitral valve segment and successively the subvalvular apparatus—including the anterior leaflet, P1, P3, chordae tendineae, and anterolateral and posteromedial papillary muscles—were checked carefully.Figure 1 shows the key procedures involved in this novel technique. The height of the prolapsed P2 segment was measured using a small scale; then, 2 dots on the P2 segment located approximately 1.5 to 2 cm perpendicular to the mitral annulus were made, and these were set as the artificial chordae implantation sites. A polytetrafluoroethylene (PTFE) suture (CV-4 Gore-Tex; WL Gore & Associates Inc) was passed through the fibrous tip of the anterolateral papillary muscle using the figure-of-eight suture technique. Each arm of the PTFE suture was passed through the left target dot twice via the plicated double-layer leaflet to create length-adjustable neochordae. The same process was repeated for the posteromedial papillary muscle and the right target dot. Consequently, plication of the redundant leaflet was achieved through the axis comprising the 2 target dots. A semirigid annuloplasty ring was then implanted, and saline solution was injected into the left ventricle to assess valvular competence. The neochordal length was regulated in case of residual mitral regurgitation (MR). A saline test was performed to verify whether the coaptation height was satisfactory, and the 2 PTFE sutures were then tied respectively with at least 10 knots on the atrial plane of the posterior leaflet. Finally, the atrium was closed, and the patient was weaned from cardiopulmonary bypass after we confirmed the absence of residual regurgitation using transesophageal echocardiography (Video 1).Figure 1Key procedures of the novel technique. A, Two dots on the P2 segment located approximately 1.5 to 2.0 cm perpendicular to the mitral annulus chosen as the artificial chordae implantation sites. B and C, the polytetrafluoroethylene sutures being passed via the 2 dots through the plicated double-layer leaflet. D, Two length-adjustable neochordae implantations. E, Implantation of the semi-rigid annuloplasty ring. F, Diagram showing the lateral view of leaflet plication with neochordae implantation.View Large Image Figure ViewerDownload Hi-res image Download (PPT)ResultsOf the 10 patients, 7 (70.0%) were male, and the mean patient age was 55.5 ± 6.6 years. Severe, moderate-to-severe, and moderate MR were observed in 4 (40.0%), 4 (40.0%), and 2 (20.0%) patients, respectively. All of the patients underwent mitral valve repair using our novel technique. No deaths or major adverse events occurred after surgery, and all the patients had an uneventful recovery. A 3-month follow-up was conducted in all patients after the surgery, and none of the patients developed recurrent MR. Detailed changes in the transthoracic echocardiographic data before surgery and at follow-up are presented in Table 1.Table 1Detailed change of echocardiographic data of all patientsVariablePreoperationFollow-upP valueLVEDV, mL134 ± 34100 ± 25.004LVESV, mL42 ± 1434 ± 8.039LVDd, mm58 ± 751 ± 5.013LVDs, mm37 ± 534 ± 3.034LVEF, %69 ± 566 ± 4.317Values are presented as mean ± standard deviation. LVEDV, Left ventricular end-diastolic volume; LVESV, left ventricular end-systolic volume; LVDd, left ventricular end-diastolic diameter; LVDs, left ventricular end-systolic diameter; LVEF, left ventricular ejection fraction. Open table in a new tab DiscussionLeaflet resection followed by either annular plication or sliding leaflet plasty demonstrated excellent long-term outcomes and is hence the classic approach for repairing posterior leaflet prolapse.6Perier P. Stumpf J. Gotz C. Lakew F. Schneider A. Clausnizer B. et al.Valve repair for mitral regurgitation caused by isolated prolapse of the posterior leaflet.Ann Thorac Surg. 1997; 64: 445-450Abstract Full Text PDF PubMed Scopus (52) Google Scholar,7Johnston D.R. Gillinov A.M. Blackstone E.H. Griffin B. Stewart W. Sabik III, J.F. et al.Surgical repair of posterior mitral valve prolapse: implications for guidelines and percutaneous repair.Ann Thorac Surg. 2010; 89: 1385-1394Abstract Full Text Full Text PDF PubMed Scopus (71) Google Scholar However, both the resection techniques share the following drawbacks8Perier P. Hohenberger W. Lakew F. Diegeler A. Prolapse of the posterior leaflet: resect or respect.Ann Cardiothorac Surg. 2015; 4: 273-277PubMed Google Scholar: (1) chordae elongation caused by long-term MR may result in residual prolapse; (2) excess posterior leaflet tissue may cause SAM; and (3) extensive resection of P2 may result in an insufficient coaptation height. Thus, unsatisfactory repair results are inevitable. The “respect approach” for mitral valve repair, which preserves the leaflet tissue, is being widely used in recent years and presents long-term outcomes comparable with those of resection techniques.3Perier P. Hohenberger W. Lakew F. Batz G. Urbanski P. Zacher M. et al.Toward a new paradigm for the reconstruction of posterior leaflet prolapse: midterm results of the “respect rather than resect” approach.Ann Thorac Surg. 2008; 86: 718-725Abstract Full Text Full Text PDF PubMed Scopus (183) Google Scholar,9Lawrie G.M. Earle E.A. Earle N.R. Feasibility and intermediate term outcome of repair of prolapsing anterior mitral leaflets with artificial chordal replacement in 152 patients.Ann Thorac Surg. 2006; 81: 849-856Abstract Full Text Full Text PDF PubMed Scopus (52) Google Scholar Although the artificial chordae length can be adjusted to an extent, dealing with a redundant posterior leaflet seems ineffective. One derived technique10Calafiore A.M. Di Mauro M. Actis-Dato G. Iaco A.L. Centofanti P. Forsennati P. et al.Longitudinal plication of the posterior leaflet in myxomatous disease of the mitral valve.Ann Thorac Surg. 2006; 81: 1909-1910Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar that reduced the length of the P2 segment through longitudinal plication in the leaflet root showed outstanding early outcomes; however, the method was complicated and time-consuming.Our technique is easy to perform and presents excellent outcomes in the repair of redundant prolapsing P2 segment. Unlike the technique of Calafiore and colleagues,10Calafiore A.M. Di Mauro M. Actis-Dato G. Iaco A.L. Centofanti P. Forsennati P. et al.Longitudinal plication of the posterior leaflet in myxomatous disease of the mitral valve.Ann Thorac Surg. 2006; 81: 1909-1910Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar which demands 3 to 6 interrupted “U” sutures passing from the annulus to P2 to decrease the height of the prolapsed P2 segment, our technique allowed us to directly implant the artificial chordae on the P2 segment approximately 1.5 to 2 cm perpendicular to the mitral annulus and plicate the prolapsed leaflet. Our technique not only prevents left ventricular outflow tract obstruction with SAM by means of the excess posterior leaflet tissue but also reduces the tension between the leaflet tissue and artificial chordae to avoid avulsion. Moreover, our technique can be used to repair other leaflets; in fact, the technique has shown remarkable results in several of our previous cases. Nevertheless, a longer follow-up duration and a larger patient cohort are needed to demonstrate the durability and stability of our novel technique. We proposed leaflet plication with neochordae implantation as a novel technique for repairing the redundant prolapsing P2 segment. We proposed leaflet plication with neochordae implantation as a novel technique for repairing the redundant prolapsing P2 segment. The middle scallop of the posterior leaflet (P2) is the most common site of mitral valve prolapse, and mitral valve repair is superior to mitral valve replacement in the treatment of degenerative mitral valve prolapse.1Suri R.M. Clavel M.A. Schaff H.V. Michelena H.I. Huebner M. Nishimura R.A. et al.Effect of recurrent mitral regurgitation following degenerative mitral valve repair: long-term analysis of competing outcomes.J Am Coll Cardiol. 2016; 67: 488-498Crossref PubMed Scopus (145) Google Scholar Carpentier's method of quadrangular resection with annular plication2Carpentier A. Cardiac valve surgery—the “French correction.”.J Thorac Cardiovasc Surg. 1983; 86: 323-337Abstract Full Text PDF PubMed Google Scholar is considered the gold standard for the treatment of mitral valve prolapse of the posterior leaflet; moreover, this revolutionary nonresection method conducted using artificial chordae has long-term effects comparable with those of leaflet resection.3Perier P. Hohenberger W. Lakew F. Batz G. Urbanski P. Zacher M. et al.Toward a new paradigm for the reconstruction of posterior leaflet prolapse: midterm results of the “respect rather than resect” approach.Ann Thorac Surg. 2008; 86: 718-725Abstract Full Text Full Text PDF PubMed Scopus (183) Google Scholar However, for redundant posterior leaflets, an extra “sliding leaflet plasty”4Perier P. Clausnizer B. Mistarz K. Carpentier “sliding leaflet” technique for repair of the mitral valve: early results.Ann Thorac Surg. 1994; 57: 383-386Abstract Full Text PDF PubMed Scopus (63) Google Scholar or the “butterfly resection technique”5Asai T. The butterfly technique.Ann Cardiothorac Surg. 2015; 4: 370-375PubMed Google Scholar is warranted to decrease the height of the posterior leaflet and avoid systolic anterior motion (SAM). Sliding leaflet plasty and butterfly resection are somewhat complicated and time-consuming. Herein, we introduce a novel, simplified mitral valve repair technique involving leaflet plication using artificial chordae implantation for the redundant prolapsing P2 segment. Surgical TechniqueThe technique was performed in 10 patients, and all of them provided written informed consent. A minimally invasive approach was employed, and cardiopulmonary bypass was established by femoral arterial and venous cannulation. A right minithoracotomy with a 5-cm-long incision was performed over the fourth intercostal space. After we temporarily arrested the heart using antegrade cold blood cardioplegia, the left atrium was accessed via the interatrial groove. The prolapsed P2 was gently lifted with forceps; then, each mitral valve segment and successively the subvalvular apparatus—including the anterior leaflet, P1, P3, chordae tendineae, and anterolateral and posteromedial papillary muscles—were checked carefully.Figure 1 shows the key procedures involved in this novel technique. The height of the prolapsed P2 segment was measured using a small scale; then, 2 dots on the P2 segment located approximately 1.5 to 2 cm perpendicular to the mitral annulus were made, and these were set as the artificial chordae implantation sites. A polytetrafluoroethylene (PTFE) suture (CV-4 Gore-Tex; WL Gore & Associates Inc) was passed through the fibrous tip of the anterolateral papillary muscle using the figure-of-eight suture technique. Each arm of the PTFE suture was passed through the left target dot twice via the plicated double-layer leaflet to create length-adjustable neochordae. The same process was repeated for the posteromedial papillary muscle and the right target dot. Consequently, plication of the redundant leaflet was achieved through the axis comprising the 2 target dots. A semirigid annuloplasty ring was then implanted, and saline solution was injected into the left ventricle to assess valvular competence. The neochordal length was regulated in case of residual mitral regurgitation (MR). A saline test was performed to verify whether the coaptation height was satisfactory, and the 2 PTFE sutures were then tied respectively with at least 10 knots on the atrial plane of the posterior leaflet. Finally, the atrium was closed, and the patient was weaned from cardiopulmonary bypass after we confirmed the absence of residual regurgitation using transesophageal echocardiography (Video 1). The technique was performed in 10 patients, and all of them provided written informed consent. A minimally invasive approach was employed, and cardiopulmonary bypass was established by femoral arterial and venous cannulation. A right minithoracotomy with a 5-cm-long incision was performed over the fourth intercostal space. After we temporarily arrested the heart using antegrade cold blood cardioplegia, the left atrium was accessed via the interatrial groove. The prolapsed P2 was gently lifted with forceps; then, each mitral valve segment and successively the subvalvular apparatus—including the anterior leaflet, P1, P3, chordae tendineae, and anterolateral and posteromedial papillary muscles—were checked carefully. Figure 1 shows the key procedures involved in this novel technique. The height of the prolapsed P2 segment was measured using a small scale; then, 2 dots on the P2 segment located approximately 1.5 to 2 cm perpendicular to the mitral annulus were made, and these were set as the artificial chordae implantation sites. A polytetrafluoroethylene (PTFE) suture (CV-4 Gore-Tex; WL Gore & Associates Inc) was passed through the fibrous tip of the anterolateral papillary muscle using the figure-of-eight suture technique. Each arm of the PTFE suture was passed through the left target dot twice via the plicated double-layer leaflet to create length-adjustable neochordae. The same process was repeated for the posteromedial papillary muscle and the right target dot. Consequently, plication of the redundant leaflet was achieved through the axis comprising the 2 target dots. A semirigid annuloplasty ring was then implanted, and saline solution was injected into the left ventricle to assess valvular competence. The neochordal length was regulated in case of residual mitral regurgitation (MR). A saline test was performed to verify whether the coaptation height was satisfactory, and the 2 PTFE sutures were then tied respectively with at least 10 knots on the atrial plane of the posterior leaflet. Finally, the atrium was closed, and the patient was weaned from cardiopulmonary bypass after we confirmed the absence of residual regurgitation using transesophageal echocardiography (Video 1). ResultsOf the 10 patients, 7 (70.0%) were male, and the mean patient age was 55.5 ± 6.6 years. Severe, moderate-to-severe, and moderate MR were observed in 4 (40.0%), 4 (40.0%), and 2 (20.0%) patients, respectively. All of the patients underwent mitral valve repair using our novel technique. No deaths or major adverse events occurred after surgery, and all the patients had an uneventful recovery. A 3-month follow-up was conducted in all patients after the surgery, and none of the patients developed recurrent MR. Detailed changes in the transthoracic echocardiographic data before surgery and at follow-up are presented in Table 1.Table 1Detailed change of echocardiographic data of all patientsVariablePreoperationFollow-upP valueLVEDV, mL134 ± 34100 ± 25.004LVESV, mL42 ± 1434 ± 8.039LVDd, mm58 ± 751 ± 5.013LVDs, mm37 ± 534 ± 3.034LVEF, %69 ± 566 ± 4.317Values are presented as mean ± standard deviation. LVEDV, Left ventricular end-diastolic volume; LVESV, left ventricular end-systolic volume; LVDd, left ventricular end-diastolic diameter; LVDs, left ventricular end-systolic diameter; LVEF, left ventricular ejection fraction. Open table in a new tab Of the 10 patients, 7 (70.0%) were male, and the mean patient age was 55.5 ± 6.6 years. Severe, moderate-to-severe, and moderate MR were observed in 4 (40.0%), 4 (40.0%), and 2 (20.0%) patients, respectively. All of the patients underwent mitral valve repair using our novel technique. No deaths or major adverse events occurred after surgery, and all the patients had an uneventful recovery. A 3-month follow-up was conducted in all patients after the surgery, and none of the patients developed recurrent MR. Detailed changes in the transthoracic echocardiographic data before surgery and at follow-up are presented in Table 1. Values are presented as mean ± standard deviation. LVEDV, Left ventricular end-diastolic volume; LVESV, left ventricular end-systolic volume; LVDd, left ventricular end-diastolic diameter; LVDs, left ventricular end-systolic diameter; LVEF, left ventricular ejection fraction. DiscussionLeaflet resection followed by either annular plication or sliding leaflet plasty demonstrated excellent long-term outcomes and is hence the classic approach for repairing posterior leaflet prolapse.6Perier P. Stumpf J. Gotz C. Lakew F. Schneider A. Clausnizer B. et al.Valve repair for mitral regurgitation caused by isolated prolapse of the posterior leaflet.Ann Thorac Surg. 1997; 64: 445-450Abstract Full Text PDF PubMed Scopus (52) Google Scholar,7Johnston D.R. Gillinov A.M. Blackstone E.H. Griffin B. Stewart W. Sabik III, J.F. et al.Surgical repair of posterior mitral valve prolapse: implications for guidelines and percutaneous repair.Ann Thorac Surg. 2010; 89: 1385-1394Abstract Full Text Full Text PDF PubMed Scopus (71) Google Scholar However, both the resection techniques share the following drawbacks8Perier P. Hohenberger W. Lakew F. Diegeler A. Prolapse of the posterior leaflet: resect or respect.Ann Cardiothorac Surg. 2015; 4: 273-277PubMed Google Scholar: (1) chordae elongation caused by long-term MR may result in residual prolapse; (2) excess posterior leaflet tissue may cause SAM; and (3) extensive resection of P2 may result in an insufficient coaptation height. Thus, unsatisfactory repair results are inevitable. The “respect approach” for mitral valve repair, which preserves the leaflet tissue, is being widely used in recent years and presents long-term outcomes comparable with those of resection techniques.3Perier P. Hohenberger W. Lakew F. Batz G. Urbanski P. Zacher M. et al.Toward a new paradigm for the reconstruction of posterior leaflet prolapse: midterm results of the “respect rather than resect” approach.Ann Thorac Surg. 2008; 86: 718-725Abstract Full Text Full Text PDF PubMed Scopus (183) Google Scholar,9Lawrie G.M. Earle E.A. Earle N.R. Feasibility and intermediate term outcome of repair of prolapsing anterior mitral leaflets with artificial chordal replacement in 152 patients.Ann Thorac Surg. 2006; 81: 849-856Abstract Full Text Full Text PDF PubMed Scopus (52) Google Scholar Although the artificial chordae length can be adjusted to an extent, dealing with a redundant posterior leaflet seems ineffective. One derived technique10Calafiore A.M. Di Mauro M. Actis-Dato G. Iaco A.L. Centofanti P. Forsennati P. et al.Longitudinal plication of the posterior leaflet in myxomatous disease of the mitral valve.Ann Thorac Surg. 2006; 81: 1909-1910Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar that reduced the length of the P2 segment through longitudinal plication in the leaflet root showed outstanding early outcomes; however, the method was complicated and time-consuming.Our technique is easy to perform and presents excellent outcomes in the repair of redundant prolapsing P2 segment. Unlike the technique of Calafiore and colleagues,10Calafiore A.M. Di Mauro M. Actis-Dato G. Iaco A.L. Centofanti P. Forsennati P. et al.Longitudinal plication of the posterior leaflet in myxomatous disease of the mitral valve.Ann Thorac Surg. 2006; 81: 1909-1910Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar which demands 3 to 6 interrupted “U” sutures passing from the annulus to P2 to decrease the height of the prolapsed P2 segment, our technique allowed us to directly implant the artificial chordae on the P2 segment approximately 1.5 to 2 cm perpendicular to the mitral annulus and plicate the prolapsed leaflet. Our technique not only prevents left ventricular outflow tract obstruction with SAM by means of the excess posterior leaflet tissue but also reduces the tension between the leaflet tissue and artificial chordae to avoid avulsion. Moreover, our technique can be used to repair other leaflets; in fact, the technique has shown remarkable results in several of our previous cases. Nevertheless, a longer follow-up duration and a larger patient cohort are needed to demonstrate the durability and stability of our novel technique. Leaflet resection followed by either annular plication or sliding leaflet plasty demonstrated excellent long-term outcomes and is hence the classic approach for repairing posterior leaflet prolapse.6Perier P. Stumpf J. Gotz C. Lakew F. Schneider A. Clausnizer B. et al.Valve repair for mitral regurgitation caused by isolated prolapse of the posterior leaflet.Ann Thorac Surg. 1997; 64: 445-450Abstract Full Text PDF PubMed Scopus (52) Google Scholar,7Johnston D.R. Gillinov A.M. Blackstone E.H. Griffin B. Stewart W. Sabik III, J.F. et al.Surgical repair of posterior mitral valve prolapse: implications for guidelines and percutaneous repair.Ann Thorac Surg. 2010; 89: 1385-1394Abstract Full Text Full Text PDF PubMed Scopus (71) Google Scholar However, both the resection techniques share the following drawbacks8Perier P. Hohenberger W. Lakew F. Diegeler A. Prolapse of the posterior leaflet: resect or respect.Ann Cardiothorac Surg. 2015; 4: 273-277PubMed Google Scholar: (1) chordae elongation caused by long-term MR may result in residual prolapse; (2) excess posterior leaflet tissue may cause SAM; and (3) extensive resection of P2 may result in an insufficient coaptation height. Thus, unsatisfactory repair results are inevitable. The “respect approach” for mitral valve repair, which preserves the leaflet tissue, is being widely used in recent years and presents long-term outcomes comparable with those of resection techniques.3Perier P. Hohenberger W. Lakew F. Batz G. Urbanski P. Zacher M. et al.Toward a new paradigm for the reconstruction of posterior leaflet prolapse: midterm results of the “respect rather than resect” approach.Ann Thorac Surg. 2008; 86: 718-725Abstract Full Text Full Text PDF PubMed Scopus (183) Google Scholar,9Lawrie G.M. Earle E.A. Earle N.R. Feasibility and intermediate term outcome of repair of prolapsing anterior mitral leaflets with artificial chordal replacement in 152 patients.Ann Thorac Surg. 2006; 81: 849-856Abstract Full Text Full Text PDF PubMed Scopus (52) Google Scholar Although the artificial chordae length can be adjusted to an extent, dealing with a redundant posterior leaflet seems ineffective. One derived technique10Calafiore A.M. Di Mauro M. Actis-Dato G. Iaco A.L. Centofanti P. Forsennati P. et al.Longitudinal plication of the posterior leaflet in myxomatous disease of the mitral valve.Ann Thorac Surg. 2006; 81: 1909-1910Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar that reduced the length of the P2 segment through longitudinal plication in the leaflet root showed outstanding early outcomes; however, the method was complicated and time-consuming. Our technique is easy to perform and presents excellent outcomes in the repair of redundant prolapsing P2 segment. Unlike the technique of Calafiore and colleagues,10Calafiore A.M. Di Mauro M. Actis-Dato G. Iaco A.L. Centofanti P. Forsennati P. et al.Longitudinal plication of the posterior leaflet in myxomatous disease of the mitral valve.Ann Thorac Surg. 2006; 81: 1909-1910Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar which demands 3 to 6 interrupted “U” sutures passing from the annulus to P2 to decrease the height of the prolapsed P2 segment, our technique allowed us to directly implant the artificial chordae on the P2 segment approximately 1.5 to 2 cm perpendicular to the mitral annulus and plicate the prolapsed leaflet. Our technique not only prevents left ventricular outflow tract obstruction with SAM by means of the excess posterior leaflet tissue but also reduces the tension between the leaflet tissue and artificial chordae to avoid avulsion. Moreover, our technique can be used to repair other leaflets; in fact, the technique has shown remarkable results in several of our previous cases. Nevertheless, a longer follow-up duration and a larger patient cohort are needed to demonstrate the durability and stability of our novel technique. Supplementary Datahttps://www.jtcvstechniques.org/cms/asset/2898a427-6172-4c42-98c8-cbdb0c52556a/mmc1.mp4Loading ... Download .mp4 (116.86 MB) Help with .mp4 files Video 1This video demonstrates the procedure of leaflet plication with neochordae implantation for the redundant posterior leaflet prolapse. Video available at: https://www.jtcvs.org/article/S2666-2507(22)00386-8/fulltext. Download .jpg (.36 MB) Help with files Video 1This video demonstrates the procedure of leaflet plication with neochordae implantation for the redundant posterior leaflet prolapse. Video available at: https://www.jtcvs.org/article/S2666-2507(22)00386-8/fulltext. https://www.jtcvstechniques.org/cms/asset/2898a427-6172-4c42-98c8-cbdb0c52556a/mmc1.mp4Loading ... Download .mp4 (116.86 MB) Help with .mp4 files Video 1This video demonstrates the procedure of leaflet plication with neochordae implantation for the redundant posterior leaflet prolapse. Video available at: https://www.jtcvs.org/article/S2666-2507(22)00386-8/fulltext. Download .jpg (.36 MB) Help with files Video 1This video demonstrates the procedure of leaflet plication with neochordae implantation for the redundant posterior leaflet prolapse. Video available at: https://www.jtcvs.org/article/S2666-2507(22)00386-8/fulltext.