The presence of a flail leaflet is not a contraindication for the procedure, since the flail segment can be resuspended by the edge-to-edge method. In this case the location of the edge-to-edge suture will be determined by the position of the flail.
Small valve area is a contraindication for the edge-to-edge technique, since it is an increasing risk factor for postoperative mitral stenosis. However, in Barlow's disease, valve area is usually excessively wide, due to annular dilatation and to tissue redundancy.
Annular calcifications are not a contraindication for the edge-to-edge technique, however, when the annulus is widely and completely calcified, an annular ring prosthesis cannot be added to the procedure, and this has been associated with higher risk of late failure of the repair. We currently do not advocate the edge-to-edge repair as an isolated procedure in presence of severely calcified annulus.
Excessive leaflet fibrosis and rigidity is another contraindication (rare in the setting of Barlow's disease), since post-repair area depends on leaflet pliability.