The advantages of the folding valvuloplasty include technical simplicity and broad applicability, especially when performed robotically. Additionally, this technique allows a surgeon to undo and adjust the height of leaflet with minimal effort. Occasionally, we have found poor coaptation from an overly shortened posterior leaflet. This is corrected by removing and re-inserting folding plasty sutures after the annuloplasty ring is inserted.

Although a folding valvuloplasty can be used for any segment of posterior leaflet prolapse, we avoid this technique in patients with ruptured chords or flail leaflets. The folding leaflet-plasty should be avoided in the presence of papillary muscle rupture or a flail leaflet. It is feasible to combine a quadrangular resection and leaflet folding-plasty when multiple pathologies include a flail leaflet and a prolapsed posterior leaflet. In this situation a quadrangular resection can be performed, followed by a leaflet folding-plasty. Moreover, a leaflet folding-plasty can be performed after a quadrangular resection if P₁ or P₃ remains redundant following approximation of the remnant leaflet. Commissuroplasty is another simple technique not requiring leaflet resection (Fig. 16.3).