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editorial
. 2021 Oct 9;10:66–67. doi: 10.1016/j.xjtc.2021.10.006

Commentary: The Barlow valve: Understanding disease and symmetry

Carlos A Mestres a,b,∗, Miguel A Piñón c, Eduard Quintana d
PMCID: PMC8691901  PMID: 34984362

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Carlos A. Mestres, MD, PhD, FETCS (left), Miguel A. Piñón, MD, PhD (center), and Eduard Quintana, MD, PhD, FETCS (right)

Central Message.

This historical summary of the main aspects of the Barlow valve helps readers to understand the complexity of this pathoanatomical and functional disease and the best approach for successful surgery.

See Article page 58.

Mitral valve repair is the gold standard in the surgery of degenerative mitral valve disease, a solidly established option supported by practice guidelines1 despite discussion.2 The main goal of repair is achieving valve competence.3 Of special interest is the complex described by the late John Barlow in 1963, known as the Barlow valve or Barlow disease. His description of late systolic murmur and malignant cardiac arrhythmias triggered by mitral valve prolapse4 opened a new era in the investigation of the mitral valve.

The Barlow valve still poses technical challenges to surgeons due to its multifaceted pathoanatomical presentation with bileaflet involvement with abnormally thickened leaflet tissue, gross involvement of the subvalvular apparatus, and annular dilatation.5 The main aspects of the disease are too much leaflet tissue and abnormal annular function. Pooling this all together, one understands that correction of the Barlow valve is more complex than for other disease forms. This complexity influences outcomes, although experienced centers report freedom from reoperation for regurgitation of 85% to 90% at 10 years.6, 7, 8

In this issue of the Journal, Barlow and colleagues9 briefly review this complex anatomical–functional interaction,9 a very useful historical summary. As we previously pointed out, history helps in understanding.10 This is the case here. Why? John Barlow started from the clinical observation and examination of patients with a mid-systolic click and late systolic murmur and palpitations, based on his interest in cardiac sounds,11 before echocardiography. From there, the Barlow valve has been established as individual entity.5 Modern echocardiography has helped to better understand the sequence of events until mitral regurgitation becomes significant.12,13 Surgical experiences with follow-up outcomes allowed us to confirm these valves are amenable for repair.3

Additional investigations showed that pathoanatomic changes in the form of annular abnormalities like disjunction should not be separated from the disease complex.14 The annular “instability” also may play a role in the development of ventricular arrhythmias.15 There is ongoing research regarding genetic etiology in mitral valve prolapse, something unknown with few genes identified. Van Wijngaarden and colleagues16 suggest some association between cardiomyopathy genes and prolapse, needing further investigation.

Surgery of the Barlow valve aims at restoring competence, releasing leaflet tension, and achieving leaflet coaptation. Another issue is like in other repairs what may eventually happen with the left ventricle17 or if surgery should be performed before significant regurgitation develops.9 Considering the Barlow valve, symmetry is also an issue, as there is bileaflet billowing and prolapse. The disease cannot easily be replicated as a regular P2 prolapse in a model for bench simulation. Imbrie-Moore and colleagues18 developed a cross-species model of the disease for biomechanical analyses of repair techniques in an ex vivo model. With all the limitations in mind, it may help improving knowledge and test the ability to repair.

This elegant and comprehensive historical review of Barlow and colleagues on the Barlow valve8 is another call for attention to the importance of reviewing history to understand the present and imagine the future.

Footnotes

Disclosures: The authors reported no conflicts of interest.

The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest.

References

  • 1.Otto C.M., Nishimura R.A., Bonow R.O., Carabello B.A., Erwin J.P., III, Gentile F., et al. 2020 ACC/AHA guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Joint Committee on clinical practice guidelines. Circulation. 2021;143:e72–e227. doi: 10.1161/CIR.0000000000000923. [DOI] [PubMed] [Google Scholar]
  • 2.Enriquez-Sarano M., Suri R.M., Clavel M.A., Mantovani F., Michelena H.I., Pislaru S., et al. Is there an outcome penalty linked to guideline-based indications for valvular surgery? Early and long-term analysis of patients with organic mitral regurgitation. J Thorac Cardiovasc Surg. 2015;150:50–58. doi: 10.1016/j.jtcvs.2015.04.009. [DOI] [PubMed] [Google Scholar]
  • 3.Dreyfus G.D., Dulguerov F., Marcacci C., Haley S.R., Gkouma A., Dommerc C., et al. “Respect when you can, resect when you should”: a realistic approach to posterior leaflet mitral valve repair. J Thorac Cardiovasc Surg. 2018;156:1856–1866. doi: 10.1016/j.jtcvs.2018.05.017. [DOI] [PubMed] [Google Scholar]
  • 4.Barlow J.B., Pocock W.A. The significance of late systolic murmurs and mid late systolic clicks. Md State Med J. 1963;12:76–77. [PubMed] [Google Scholar]
  • 5.Anyanwu A.C., Adams D.H. Etiologic classification of degenerative mitral valve disease: Barlow's disease and fibroelastic deficiency. Semin Thorac Cardiovasc Surg. 2007;19:90–96. doi: 10.1053/j.semtcvs.2007.04.002. [DOI] [PubMed] [Google Scholar]
  • 6.Anyanwu A.C., Adams D.H. Bileaflet repair for Barlow syndrome. Semin Thorac Cardiovasc Surg. 2010;22:179–183. doi: 10.1053/j.semtcvs.2010.09.005. [DOI] [PubMed] [Google Scholar]
  • 7.Borger M.A., Kaeding A.F., Seeburger J., Melnitchouk S., Hoebartner M., Winkfein M., et al. Minimally invasive mitral valve repair in Barlow's disease: early and long-term results. J Thorac Cardiovasc Surg. 2014;148:1379–1385. doi: 10.1016/j.jtcvs.2013.11.030. [DOI] [PubMed] [Google Scholar]
  • 8.da Rocha E Silva J.G., Spampinato R., Misfeld M., Seeburger J., Pfanmüller B., Eifert S., et al. Barlow's mitral valve disease: a comparison of neochordal (loop) and edge-to-edge (Alfieri) minimally invasive repair techniques. Ann Thorac Surg. 2015;100:2127–2133. doi: 10.1016/j.athoracsur.2015.05.097. [DOI] [PubMed] [Google Scholar]
  • 9.Barlow C.W., Ali-Ghosh H., Sajiram S. Functional anatomy and surgical principles of mitral repair for the Barlow valve: past legacy guides the future. J Thorac Cardiovasc Surg Tech. 2021;10:58–63. doi: 10.1016/j.xjtc.2021.08.046. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 10.Mestres C.A. Do not forget to read history: you will understand and improve. J Thorac Cardiovasc Surg Tech. September 6, 2021 doi: 10.1016/j.xjtc.2021.09.007. [Epub ahead of print] [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 11.Barlow J.B. Some observations on the atrial sound. S Afr Med J. 1960;34:887–892. [PubMed] [Google Scholar]
  • 12.van Wijngaarden S.E., Kamperidis V., Regeer M.V., Palmen M., Schalij M.J., Klautz R.J., et al. Three-dimensional assessment of mitral valve annulus dynamics and impact on quantification of mitral regurgitation. Eur Heart J Cardiovasc Imaging. 2018;19:176–184. doi: 10.1093/ehjci/jex001. [DOI] [PubMed] [Google Scholar]
  • 13.Hiemstra Y.L., Tomsic A., Gripari P., van Wijngaarden A.L., van der Pas S.L., Palmen M., et al. Evolution from mitral annular dysfunction to severe mitral regurgitation in Barlow's disease. Interact Cardiovasc Thorac Surg. 2021;32:506–514. doi: 10.1093/icvts/ivaa304. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 14.Faletra F.F., Leo L.A., Paiocchi V.L., Schlossbauer S.A., Pavon A.G., Ho S.Y., et al. Morphology of mitral annular disjunction in mitral valve prolapse. J Am Soc Echocardiogr. September 8, 2021 doi: 10.1016/j.echo.2021.09.002. [Epub ahead of print] [DOI] [PubMed] [Google Scholar]
  • 15.van Wijngaarden A.L., de Riva M., Hiemstra Y.L., van der Bijl P., Fortuni F., Bax J.J., et al. Parameters associated with ventricular arrhythmias in mitral valve prolapse with significant regurgitation. Heart. 2021;107:411–418. doi: 10.1136/heartjnl-2020-317451. [DOI] [PubMed] [Google Scholar]
  • 16.van Wijngaarden A.L., Hiemstra Y.L., Koopmann T.T., Ruivenkamp C.A.L., Aten E., Schalij M.J., et al. Identification of known and unknown genes associated with mitral valve prolapse using an exome slice methodology. J Med Genet. 2020;57:843–850. doi: 10.1136/jmedgenet-2019-106715. [DOI] [PubMed] [Google Scholar]
  • 17.Quintana E., Suri R.M., Thalji N.M., Daly R.C., Dearani J.A., Burkhart H.M., et al. Left ventricular dysfunction after mitral valve repair—the fallacy of “normal” preoperative myocardial function. J Thorac Cardiovasc Surg. 2014;148:2752–2760. doi: 10.1016/j.jtcvs.2014.07.029. [DOI] [PubMed] [Google Scholar]
  • 18.Imbrie-Moore A.M., Paulsen M.J., Zhu Y., Wang H., Lucian H.J., Farry J.M., et al. A novel cross-species model of Barlow's disease to biomechanically analyze repair techniques in an ex vivo left heart simulator. J Thorac Cardiovasc Surg. 2021;161:1776–1783. doi: 10.1016/j.jtcvs.2020.01.086. [DOI] [PMC free article] [PubMed] [Google Scholar]

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