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Ann Thorac Surg 1995;60:225-226
© 1995 The Society of Thoracic Surgeons

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Updates

Mitral Valve Replacement With Preservation of Chordae Tendineae and Papillary Muscles

As Originally Published in 1988:

Updated in 1995 by Shigehito Miki, MD, Yuichi Ueda, MD, Takafumi Tahata, MD, and Yutaka Okita, MD

Department of Cardiovascular Surgery, Tenri Hospital, Tenri, Nara, Japan

Since we published our article entitled ``Mitral Valve Replacement With Preservation of Chordae Tendineae and Papillary Muscles'' in The Annals [1], this technique has been our standard procedure for mitral valve replacement (MVR) for mitral regurgitation. We performed this operation in 18 patients after the first report of this operation with no deaths [2], and the total number was 40 by the end of November 1994. Comparison of the results of this technique with the conventional MVR and mitral repair already was reported by one of us [2, 3]. In the early postoperative period, left ventricular end-systolic volume index and end-diastolic pressure were significantly higher in the conventional MVR group. The left ventricular ejection fraction was unchanged in the chordal preservation group and decreased in the conventional MVR group. In the long-term evalution with the use of multigated radionuclide angiography and M-mode echocardiography, patients with chordal preservation showed better ejection fraction of the left ventricle (0.56 ± 0.21 versus 0.49 ± 0.10; p < 0.05), better left ventricular contractility index (left ventricular end-systolic circumferential stress/left ventricular end-systolic volume index) (4,063 ± 1,027 versus 3,224 ± 914 kdyn • cm^-2 • mL^-1 • m^-2; p < 0.05), better left ventricular fractional shortening (0.36 ± 0.07 versus 0.29 ± 0.08; p < 0.01), and better regional ejection fraction of the left ventricular wall at the apical septal, inferoapical, inferolateral, anterobasal, and anterolateral portions with this method. Comparison with the mitral repair revealed that postoperative left ventricular ejection fraction (0.56 ± 0.21 versus 0.54 ± 0.09; not significant) and regional fractional shortening (0.36 ± 0.07 versus 0.33 ± 0.08; not significant) were almost identical.

Recently, we had an opportunity to look at the preserved chordae tendineae and papillary muscles in a patient whose mitral valve was replaced with the use of this technique 9.5 years ago; this patient required reoperation on account of prosthetic valve dysfunction caused by thrombus formation of the posterior leaflet implanted parallel to the natural commissure. Figure 1 shows intraoperative views of this patient. These pictures suggest the tethering effect of the chordae and papillary muscles has been maintained. In this patient, the thickened area of the leaflet was partly reshaved and the bileaflet prosthetic valve was re-replaced with the valve's leaflet perpendicular to the natural commissure.

View larger version (4K): [in this window] [in a new window]   Fig 1. . Intraoperative views of the preserved mitral apparatus. (A) Viewed through the sewing ring. Prosthetic leaflets are taken away. (B) Viewed through the mitral ring. The sewing ring is taken away. The anterior half segment of the divided anterior leaflet (small black arrow), chordae tendineae (between small and large black arrows), anterolateral papillary muscle (large black arrow), posterior half segment of the divided anterior leaflet (small white arrow), and posterior leaflet (large white arrow) keep the same appearance as at the time of preservation 9.5 years ago.

In a recent experimental report, Moon and colleagues [6] disclosed that the chordal-sparing MVR showed better systolic and diastolic function compared with the conventional MVR, although the anterior chordal-sparing technique used in this report is different from the one that we are using. Tarelli and others [7] also reported better left ventricular ejection fraction in the MVR group with the preservation of annulopapillary continuity operated on by a modification of our technique than in the conventional MVR group in a randomized study on the effect of the preservation of annulopapillary continuity. These reports support the importance of maintaining papillary function in mitral valve replacement.

Our opinion about mitral valve operation at present is that papillary muscle contractility can be preserved in all types of operation—from repair to replacement—with the extended use of this technique.

Footnotes

Address reprint requests to Dr Miki, Department of Cardiovascular Surgery, Tenri Hospital, 200 Mishima, Tenri Nara Pref, Japan 632.

References

1. Miki S, Kusuhara K, Ueda Y, Komeda M, Ohkita Y, Tahata T. Mitral valve replacement with preservation of chordae tendineae and papillary muscles. Ann Thorac Surg 1988;45:28–34.[Abstract]
2. Okita Y, Miki S, Kusuhara K, et al. Analysis of left ventricular motion after mitral valve replacement with a technique of preservation of all chordae tendineae. J Thorac Cardiovasc Surg 1992;104:786–95.[Abstract]
3. Okita Y, Miki S, Ueda Y, Tahata T, Sakai T, Matsuyama K. Comparative evaluation of left ventricular performance after mitral valve repair or valve replacement with or without chordal preservation. J Heart Valve Dis 1993;2:159–66.[Medline]
4. Okita Y, Miki S, Ueda Y, Tahata T, Sakai T, Matsuyama K. Replacement of chordae tendineae using expanded polytetrafluoroethylene (ePTFE) sutures during mitral valve replacement in patients with severe mitral stenosis. J Card Surg 1993;8:567–78.[Medline]
5. Okita Y, Miki S, Ueda Y, Tahata T, Sakai T, Matsuyama K. Mitral valve replacement with maintenance of mitral annulopapillary muscle continuity in patients with mitral stenosis. J Thorac Cardiovasc Surg 1994;108:42–51.[Abstract/Free Full Text]
6. Moon MR, DeAnda A Jr, Daughters GT II, Ingels NB Jr, Miller DC. Experimental evaluation of different chordal preservation methods during mitral valve replacement. Ann Thorac Surg 1994;58:931–44.[Abstract]
7. Tarelli T, Musazzi A, Semeraro F, Ceriani L, Respigi E. Effect of the preservation of annulo-papillary continuity after mitral valve replacement. A clinical randomized study on patients affected by rheumatic valve disease. Eur J Cardiothorac Surg 1994;8:457–61.[Abstract]

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