Excess width (figure 3)
Excess width was emphasized in our 2006 publication [2]when we advocated to use small triangular resections to treat excess width; the concept was later also reinforced by Perier [4] . As stated, the purpose of addressing excess width is to create a smooth surface of coaptation, by eliminating the folding of thickened tissue. In his discussion section, Perier confessed that up to 35 % of cases required triangular resection due to excess tissue in width[4] . In comparison, we usually resect the width in most of patients (around 75%). When the rough zone has been resected, the transverse excess tissue becomes obvious as the leaflet tissue folds naturally, at the level of excess width . If the rough zone is left intact, any billowing tissue has both excess height and excess width. Resection is most often triangular with the base of the triangle being at the free edge. Should resection reach the annulus or not? Most reach the annulus and some stop in the middle; none has proven to be superior one to the other. How can a resection be assessed to avoid excess tension? In our opinion, the best criterion indicating that there is not too much resection, is to be able to apply the entire posterior leaflet without any tension along the posterior wall of the left ventricle (a physiological MV never shows such excess tissue as seen in a Barlow).