Annuloplasty
At the last stage of MVr, a conventional water test is always performed without annuloplasty ring and sutures. If the water test is not perfect, we seek for remaining problems, but we never rely on the annuloplasty to eradicate a residual leak.
We use annuloplasty rings in all patients (but alternatively, bands from one trigone to the other could be employed) measuring the size according to the unfolded anterior leaflet and always using the upper size in case of a doubt. In our view, an annuloplasty is mandatory to reshape the annulus and to decrease the tension on it. It should be stressed that annuloplasty does not promote coaptation. Coaptation should be achieved before any annuloplasty.
Finally, there are more and more concerns about the use of rings that are too small, creating dynamic mitral stenosis. In Barlow, rings and bands should be at least the same size as the anterior leaflet and probably slightly bigger.