Commissural area
The anterior and the posterior commissures are not at all alike. The
anterior commissure is rarely involved, mostly as it is well supported
by the trigone. On the contrary, the Posterior Commissure (PC) is free
of any support and most likely its involvement is underestimated. There
are obvious prolapses of the PC, and there are billowing which may seem
innocuous but may be favoring with time a recurrent regurgitation due to
its weakness.
Given that this area is all supported by many chordae arising from the
posterior papillary muscle displacing downwards the adequate head, may
correct very easily any posterior commissural prolapse. We have
described this idea as a new surgical technique that we called Papillary
Muscle Repositioning (PMR) in 2006 [7]. In our experience
it is the method of choice to treat AL and PC prolapse, due to elongated
chordae and irrespectively of the location of the lesion, with excellent
clinical and echocardiographic long-term results.
Alternatively, artificial chordae cannot easily be used as it is the
area of the valve which has as the greatest number of chordae. Many
surgeons, referring to Carpentier use what they call a commissural
plasty or “commissuroplasty “which is a complete closure of the
posterior commissure, suturing together A3 to P3. This technique is very
fast and simple. It does not promote any coaptation. Whether it is
efficient in terms of durability remains to be confirmed. As a comment,
Carpentier never closed the PC in Barlows , but described a similar
technique in rheumatic patients, for whom the PC required to be
reconstructed after complete decalcification reaching the annulus . The
PC area was reconstructed by using inverted single sutures for 6 to 10
mm, thereby recreating the PC.