Figure 7. Horizontal plication of the anterior mitral leaflet to reduce leaflet length and leaflet/chordal slack. The fibrotic area on the anterior leaflet that is the contact point between the leaflet and the septum is identified. Plication is performed by placing three to four fine mattress sutures of 5-0 polypropylene in a horizontal rather than longitudinal orientation though the fibrotic area of the leaflet. The width of the mattress sutures is dictated by the degree of redundancy of the leaflet and mobility when assessed by the nerve hook. This modification more directly reduces leaflet-chordal slack and excess length than a suture line in the longitudinal orientation. Abbreviations: Ao=aortic root, AML=anterior mitral leaflet; LMO=left main coronary ostium; NCL=non-coronary aortic leaflet.