Surgical Management Mitral valve repair as primary intervention is the rule A replacement is considered in case of failure after a few attempts to repair the valve The functional type and the mechanism of the regurgitation and/or stenosis must have been previously identified Surgery is performed under cardiopulmonary bypass with a bicaval venous cannulation The preferred approach to the mitral valve is via a left atriotomy in the atrioventricular groove, especially when the left atrium is dilated The transatrial approach after a right atriotomy is an alternative.87,88 Transesophageal echocardiography is essential perioperatively in the case of a repair Details regarding the management of the left atrioventricular valve in the setting of an atrioventricular septal defect, rheumatic heart disease, and endocarditis are provided in Chapters 31, 55, and 56, respectively Mitral Valve Repair Different techniques of repair on various parts of the valve have been described and derive from adult cardiac surgery The ultimate objective is to restore a normal function (based on the functional classification) and a satisfactory surface of coaptation but not always a normal anatomy Techniques Interventions on the Subvalvar Apparatus Most procedures on the subvalvar apparatus (papillary muscles and cords) are designed to correct a Carpentier type II anomaly (excess leaflet motion) On the Papillary Muscles Different techniques allow for shortening of papillary muscles: wedge resection (Fig 34.31) and sliding plasty (Fig 34.32) In the case of a parachute mitral valve, splitting the papillary muscle gives more motion to the valve, combined with the resection of the accessory chordal tissue (Fig 34.33) FIG 34.31 Papillary muscle edge resection FIG 34.32 Sliding plasty FIG 34.33 Three different steps to treat a parachute mitral valve Commissurotomy (A) and papillary muscle splitting (B) and fenestration of the subvalvar apparatus (C) On the Cords Insertion of neocords is the preferred option to adjust the height of the tension apparatus whether it is restricted or excessive (Fig 34.34) Repairs without foreign material include chordal shortening (Fig 34.35) and chordal transfer (Fig 34.36)