Vertical split of the posterior leaflet increases mitral valve area.

I read with interest the article by Kurazumi and colleagues about mitral valve replacement for a severely calcified annulus [1]. I congratulate the authors for their excellent results and simple technique to overcome this difficult problem. My only concern is about the valve size of 21 mm in the mitral position producing about 2 cm mitral valve area. This might be marginal for small-body-weight patients but definitely not acceptable for 70 kg or more body weight, causing patient—prosthesis mismatch. Most of the surgeons have to excise the posterior leaflet, especially in heavily diseased or calcified valves, to gain more valve area. Recent publications recommend preserving at least the posterior leaflet to keep the ventriculoannular connection and to maintain the conical shape of the ventricle and thus improving the left-ventricular function. The technique described by Kurazumi and colleagues addressed this issue, but we are still left with the small-sized prosthetic valve. To overcome this problem, I shave the posterior leaflet as much as possible and perform a vertical split of the posterior leaflet from the middle of its free edge to the annulus. This usually increases the effective orifice area to enable the surgeon to use bigger-sized valves of 25 mm and more. The authors used St. Jude Medical mechanical (SJM) heart valves (St. Jude Medical, St. Paul, USA) with a specific structure (? Regent), but I think all other supra-annular valves will do the same work.