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Ann Thorac Surg 1996;62:878-880
© 1996 The Society of Thoracic Surgeons

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Case Report

Extensive Use of Artificial Chordae for Repairing Diffuse Mitral Valve Prolapse

Departments of Cardiovascular Surgery and Cardiology, Faculty of Medicine, Kyushu University, Fukuoka, Japan

Accepted for publication March 29, 1996.

	Abstract

Top Footnotes Abstract Introduction Case Reports Comment References

 
A diffuse mitral valve prolapse was successfully repaired in 2 patients using polytetrafluoroethylene sutures as artificial chordae. In a 16-year-old boy with Marfan's syndrome and in a 56-year-old woman, a total of 11 and ten pairs of polytetrafluoroethylene sutures were used, respectively, to repair a severe mitral valve prolapse. We consider mitral valve repair using polytetrafluoroethylene sutures to be the treatment of choice for a diffuse prolapse of the mitral valve involving both the anterior and posterior leaflets.

	Introduction

Top Footnotes Abstract Introduction Case Reports Comment References

 
The procedure of mitral valve repair is generally considered to be preferable to mitral valve replacement. However, the successful repair of diffuse mitral valve prolapse of both the anterior and posterior leaflets still remains a challenge. We herein report our experience in repairing a diffuse mitral valve prolapse by means of the extensive use of polytetrafluoroethylene (PTFE) sutures in 2 patients.

	Case Reports

Top Footnotes Abstract Introduction Case Reports Comment References

 
Patient 1
Patient 1 was a 16-year-old boy with Marfan's syndrome. His past history included a sterno-turnover operation for funnel chest at the age of 4 years. His physical examination revealed a marked scoliosis and a grade 4/6 systolic murmur at the apex. A preoperative catheterization study showed a grade 4/4 mitral regurgitation on left ventricular angiography, but no aortic regurgitation was noted by aortography.

We used an extended superior septal approach to expose the mitral valve. The mitral valve annulus was markedly dilated and diffuse, and a marked prolapse of both leaflets was also found. All the chordae were elongated, but no chorda was torn. Mitral valve repair was thus performed according to David and associates' [1] method using 4-0 PTFE sutures. A total of 11 pairs of PTFE sutures were used, six of those for the anterior leaflet and the rest for the posterior leaflet (Fig 1). Each suture was placed through the body of the papillary muscle in a figure-of-8 fashion and then was tied. The double arms of each pair were passed through the edge of the leaflet from the ventricular side to the atrial side, and then were passed once more from the atrial side to the ventricular side. The lengths of the PTFE chordae were adjusted to align the edge of the leaflets to the level of the mitral annulus. Great care was taken to maintain the predetermined distance between the annulus and the left ventricular apex. We determined the distance by measuring the diastolic distance between the apex and the mitral annulus by means of a preoperative echocardiographic examination. After tying the PTFE sutures, we performed a Kay annuloplasty [2] on the both commissures with 2-0 braided polyester sutures. The competence of the valve was then tested by infusing cardioplegia into the aortic root and by intentionally creating aortic regurgitation. The left ventricular pressure measured by a double-lumen cardioplegia cannula reached 40 mm Hg. The patient's postoperative course was uneventful. Left ventricular angiography performed 1 month after the operation showed only a trace amount of mitral regurgitation. He was anticoagulated with warfarin for 3 months. An echocardiographic examination performed 11 months after the operation showed no further mitral regurgitation.

View larger version (48K): [in this window] [in a new window]   Fig 1. . Intraoperative photograph of patient 1 showing multiple polytetrafluoroethylene chordae before the sutures were tied; the sutures had already been passed through the edge of the leaflets. The patient's head is on the left.

	Comment

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Although several methods have been proposed for the repair of a mitral valve with either a prolapse or torn chordae, the application of previously available techniques has been limited to a localized lesion or a lesion involving a limited portion of the posterior leaflet [3]. In contrast, PTFE artificial chordae can be used both in torn chordae or in elongated chordae even when they are inserted into the anterior leaflet [1]. However, there have only been a few reports of using this technique on a diffuse leaflet prolapse. In Kawazoe and associates' series [4], the pairs of PTFE sutures ranged from one to six (average, 2.3 per patient). We used 11 pairs of PTFE sutures in the first patient and ten pairs in the second patient. The key to the success of using this technique is to adequately determine the length of the artificial chordae. Therefore, because there is no chorda to show the reference length in the case of diffuse mitral prolapse, we rely heavily on the findings of a preoperative echocardiographic examination. It is extremely important to maintain the predetermined distance between the apex and the mitral annulus to retain the natural geometry of the left ventricle during the operation.

We have reported 2 patients who underwent successful repair of diffuse mitral valve prolapse. Although there has yet to be adequate long-term follow-up of this procedure, at present both patients are clearly demonstrating excellent ventricular function without requiring anticoagulation therapy. We therefore conclude that the extensive use of PTFE artificial chordae appears to be a promising procedure for the repair of diffuse mitral valve prolapse.

	Footnotes

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Address reprint requests to Dr Morita, Department of Cardiovascular Surgery, Faculty of Medicine, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, Japan 812-82.

	References

Top Footnotes Abstract Introduction Case Reports Comment References

 

1. David TE, Boss J, Rakowski H. Mitral valve repair by replacement of chordae tendineae with polytetrafluoroethylene sutures. J Thorac Cardiovasc Surg 1991;101:495–501.[Abstract]
2. Kay JH, Zubiate P, Mendez MA, Vanstrom N, Yokoyama T, Gharavi MA. Surgical treatment of mitral insufficiency secondary to coronary artery disease. J Thorac Cardiovasc Surg 1980;79:12–8.[Abstract]
3. Carpentier A. Cardiac valve surgery-the "French correction."J Thorac Cardiovasc Surg 1983;86:323–37.[Medline]
4. Kawazoe K, Eishi K, Sasako Y, et al. Clinical experience of mitral valve reconstruction with artificial chordae implantation. Eur J Cardiothorac Surg 1992;6:297–301.[Abstract/Free Full Text]

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Shigeki Morita Yukihiro Tomita Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Morita, S. Articles by Tominaga, R. Search for Related Content PubMed PubMed Citation Articles by Morita, S. Articles by Tominaga, R.