FIG 34.37 Patch augmentation of the anterior leaflet FIG 34.38 Patch augmentation of the posterior leaflet with mobilization of the papillary muscle Remodeling annuloplasty with a rigid adult-size ring (4) An anterior and/or posterior commissurotomy can be performed, when appropriate, to reduce stenosis to some degree Intervention on the Annulus An isolated annuloplasty is performed in the case of an isolated annular dilation (Carpentier type I), as seen, for example, following the repair of an anomalous left coronary artery from the pulmonary artery (see Chapter 46) An annuloplasty is otherwise always associated with any other repair for mitral regurgitation except for repair of isolated clefts without annular dilation According to the weight of the patient and the diameter of the native annulus, the remodeling annuloplasty is performed with the use of compression mattress sutures in infants (Fig 34.39), a polytetrafluoroethylene band for a posterior annuloplasty in toddlers (see Fig 34.39), or a rigid adult-size ring in teenagers (see Fig 34.38) FIG 34.39 Posterior annuloplasty with compression mattress sutures (2) or a polytetrafluoroethylene band (3) Intervention on the Supraannular Level The supraannular mitral ring is rarely isolated, and it is now established that its presence is often associated with other left-sided obstructions (subaortic membrane, bicuspid aortic valve, and hypoplasia/coarctation of the aorta) and/or a VSD The repair consists in the resection of a fibrous membrane adherent to the leaflets (Fig 34.40) The outcomes are excellent if the ring is completely resected and its cause, if any, has been identified and addressed