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Evolving Concepts and Technologies in Mitral Valve Repair by Paul W.M. Fedak, Patrick M. McCarthy, and Robert O. Bonow Circulation Volume 117(7):963-974 February 19, 2008 Copyright © American Heart Association, Inc. All rights reserved. Figure 1. Carpentier developed a classification of patients with MR that is widely followed. Paul W.M. Fedak et al. Circulation. 2008;117:963-974 Copyright © American Heart Association, Inc. All rights reserved. Figure 2. The posterior leaflet is divided into 3 scallops or segments (lateral, middle, and medial scallops) identified as P1, P2, and P3. Paul W.M. Fedak et al. Circulation. 2008;117:963-974 Copyright © American Heart Association, Inc. All rights reserved. Figure 3. The relationships of the mitral valve are important. Paul W.M. Fedak et al. Circulation. 2008;117:963-974 Copyright © American Heart Association, Inc. All rights reserved. Figure 4. The mitral valve is nonplanar, although the original mitral valve rings were flat and planer. Paul W.M. Fedak et al. Circulation. 2008;117:963-974 Copyright © American Heart Association, Inc. All rights reserved. Figure 5. Degenerative MR can be treated with a variety of techniques. Paul W.M. Fedak et al. Circulation. 2008;117:963-974 Copyright © American Heart Association, Inc. All rights reserved. Figure 6. SAM can develop in patients with myxomatous MR when the coaptation point to the septal distance is reduced. Paul W.M. Fedak et al. Circulation. 2008;117:963-974 Copyright © American Heart Association, Inc. All rights reserved. Figure 7. The edge-to-edge approximation (Alfieri repair) consists of suturing the anterior and posterior leaflets together to create a “double orifice” mitral valve. Paul W.M. Fedak et al. Circulation. 2008;117:963-974 Copyright © American Heart Association, Inc. All rights reserved. Figure 8. The relationship of the coronary sinus and the mitral annulus is variable, and in 64% of patients, the circumflex coronary artery (LCX) may travel between the coronary sinus (CS) and the mitral annulus (MA) and be vulnerable to compression, which limits the practicality of the coronary sinus approach for some patients. Paul W.M. Fedak et al. Circulation. 2008;117:963-974 Copyright © American Heart Association, Inc. All rights reserved. Figure 9. The Coapsys device was designed to perform echocardiography-guided off-pump reduction or elimination of MR. The device consists of transventricular splints with an anterior pad on the right ventricular side of the septum and 2 posterior pads. Paul W.M. Fedak et al. Circulation. 2008;117:963-974 Copyright © American Heart Association, Inc. All rights reserved.