Chord transfer and leaflet management for Barlow's valve repair

Barlow's disease is one of the most challenging phenotypes of degenerative mitral valve pathology, characterized by excessive leaflet tissue, diffuse prolapse, elongated chordae, and annular dilation. Successful repair requires restoration of physiologic leaflet motion and stable coaptation and prevents systolic anterior motion. This manuscript describes an algorithmic approach for Barlow's valve repair centered on chord transfer and leaflet management. Chord transfer utilizes normally functioning secondary chords as support for prolapsing leaflet segments. By mobilizing and reattaching these chords to areas of excess height or unsupported leaflet tissue, balanced leaflet motion can be restored. The technique is detailed step-by-step, including identification of abnormal chordal structures, selection of appropriate chords and precise re-implantation to restore coaptation geometry. Additional leaflet management strategies to address Barlow's disease include cleft closure, assessing and correcting areas of asymmetry, smoothing of irregular edges. Operative images and descriptions illustrate how to safely execute these modifications while preserving leaflet integrity and subvalvular architecture. This approach aims to simplify and standardize repair with a reliable method to repair a complex Barlow's valve without use of artificial neochord implantation.