**5. Discussion**

Mitral valve has stood the test for evolution and the extreme dynamic nature brings forth a great concept of engineering skills to repair and hold on to this precious tissue. Resection creates extreme stress and should be avoided at all costs. To replace when repair is feasible is a sin with our current understanding and technological evolution. Long term durability and SAM were intriguing concepts which made surgeons adopt technological modifications, but reparability rates remained constant in the last decade in most advanced cardiac centers around the world. The understanding of the intervalvular triangle as an important part of anterior leaflet and the concept of avoiding placing a horizontal stiff ring across it was emphasized by the American correction version of mitral repairs. Mitral valve stress analysis shows at the beginning of systole the marginal chordae carries the maximum stress. Stress increases now on the strut chordae in mid systole with more of leaflet coaptation with entire stress transfer to annulus during late systole with good leaflet coaptation [2, 3]. With annular dilatation stress is evenly distributed to all valvular structures and that is the reason why mitral regurgitation tends to be a progressive disease. Normal valve dynamics ensure optimal diastolic locking, proper zone of coaptation with excellent left ventricular outflow dynamics and smooth leaflet and chordal stress distribution. Of the various geometric, kinetic and structural factors that can lead to SAM, impaired aorto mitral coupling dynamics are most significant. It is important to avoid rigid and undersized rings which not only alter coupling dynamics but reduce the aorto mitral angle [4–7] also that lead to both LV inflow and outflow obstructions. Failures to recognize the interventricular component of anterior leaflet and aortomitral coupling dynamics are important reasons for failure of repair of this segment. Avoid resection and true sized annuloplasty rings that take the interventricular triangle are keys to success. Ischemic mitral regurgitation often with sagging P2 P3 areas require annuloplasty to correct this portion and then bringing the papillary muscles to within 2cm of each other before placing the ring – for which a true sized ring would be most effective. The goals of the Indian method of correction would be explained as follows


It is an excellent reproducible and safe procedure with 0.2% mortality [8]. Failure with repair techniques to due to leaving behind areas of stress which has to be meticulously avoided by proper assessment and optimal repair [9].
