Reoperative Mitral Valve Repair After Failed Robotic Repair: An Illustrated Guide to the Mechanism of Repair Failure

Vincent Gaudiani

doi:doi:10.25373/ctsnet.31079422

Monday, January 19, 2026

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Gaudiani V, Korver K. Reoperative Mitral Valve Repair After Failed Robotic Repair: An Illustrated Guide to the Mechanism of Repair Failure. January 2026. doi:10.25373/ctsnet.31079422

The patient was suffering from hemolysis and mitral regurgitation. A hemisternotomy was performed after femoral vein cannulation. A new cross-clamp was used and is shown in the video. Cardioplegia was given, and the left atrial appendage was removed. The aorta was retracted so that the roof of the left atrium was visible and then opened with a rooftop incision. 

The previous mitral ring was removed along with its Cor-Knots, and the torn previous chords were observed. These chords did not have a large enough posterior leaflet to prevent excess tension on them, which was the reason for their failure. Sutures were placed, and a chordal-sparing 33 mm biological mitral valve replacement was performed, leaving the posterior leaflet in place. 

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Comments

Submitted by Michael Schwabe on Tue, 2026-01-20 18:40

Great video, thanks very much. Could you elaborate on what you would have done differently during the initial repair?

Submitted by Vincent Gaudiani on Wed, 2026-01-21 22:02

Yes. I am not sure the previous surgeon understood why the anterior leaflet was flail. He corrected the flail with a bunch of chords to the anterior leaflet in the A3 area, bur the flail occurred because the P3 segment had deteriorated so the A3 piece did not have a coaptation "partner". In that location the easiest fix is a Carpentier exclusion of the deficient P3 along with the anterior chordal repair

Submitted by Giuseppe Rescigno on Sun, 2026-01-25 13:13

Thank you Dr Gaudiani for this amazing video as usual. The crucial concept of coaptation area/length is frequently overlooked. Many repairs seem OK in theatre but you can already predict that they will not last very long. One thing that I do differently for a mitral valve replacement is to use everting pledgetted stitches, in particular when using a large valve like in this case. I am always worried of the pledgets in the ventricular side if a suture snaps. Kind regards

Submitted by Vincent Gaudiani on Tue, 2026-01-27 20:27

Placing pledgets on the atrial side works fine, but breaking a suture is very rare. The more calcified and difficult the annulus, the better to trap that annulus between the pledgers below and the valve annulus above. But that is just the way it works for me. Understanding why the valve stays shut in systole is far more important to good operations. Thx!

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Reoperative Mitral Valve Repair After Failed Robotic Repair: An Illustrated Guide to the Mechanism of Repair Failure

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