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Ann Thorac Surg 1997;64:1831-1834
© 1997 The Society of Thoracic Surgeons

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Case Report

Mitral Valve Repair for Isolated Double-Orifice Mitral Valve With Torn Chordae

Department of Cardiovascular Surgery, Faculty of Medicine, Kyushu University, Fukuoka, Japan

Accepted for publication August 12, 1997.

	Abstract

Top Footnotes Abstract Introduction Comment References

 
Double-orifice mitral valve is an unusual condition of importance to surgeons, and usually associated with other cardiac anomalies. This article reports a case of isolated double-outlet mitral valve with torn chordae in which we successfully performed mitral valvuloplasty by placement of artificial chordae. The mitral valve was divided into anterolateral and posteromedial orifices by vertical bridging tissue. Two torn chordae at the posteromedial scallop surrounding the posteromedial mitral orifice were replaced with artificial chordae of two pairs of expanded polytetrafluoroethylene sutures. Because replacement of torn chordae with artificial chordae was not complicated and seemed to preserve very fine relationships among leaflet tissues, bridging tissue, chordae, and papillary muscles, we suggest this method may be used to reconstruct various kinds of mitral lesions causing mitral regurgitation.

	Introduction

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Double-orifice mitral valve (DOMV), with or without associated cardiac disease, is a cardiac anomaly that is infrequently reported [1–4]. The entity, which was first referred to as double mitral valve, has been called duplication of the mitral valve and double mitral valve orifice [2–4]. The term double-orifice mitral valve was introduced by Rosenberg and Roberts [5] and by virtue of common usage may prevail. In this anomaly the valve leaflet of the two orifices found in the left atrioventricular orifice is supported by chordae tendineae originating from the papillary muscles or the atrioventricular wall. This distinguishes it from fenestrations in the valve leaflets, which do not have chordae supporting the leaflet. Although clinical diagnosis is difficult, patients with DOMV associated with endocardial cushion defect (ECD) seem not so rare [5, 6]. Patients with DOMV unassociated with other cardiac anomalies, however, are very rare and usually live a healthy life. Thus, cardiovascular surgeons rarely experience patients with isolated DOMV unless they also suffer from acquired mitral stenosis or mitral regurgitation (MR). Here, we report a successful mitral valvuloplasty of torn chordae associated with isolated DOMV, using a method of chordal replacement with polytetrafluoroethylene artificial grafts.

A 57-year-old female patient required treatment for congestive heart failure of sudden onset. She had been living a healthy life and had undergone three previous uneventful pregnancies. A regurgitant systolic murmur, grade 3/6, was audible at the apex. Left ventricular angiography showed severe MR of grade 4/4. Echocardiography provided a diagnosis of torn chordae at the posteromedial scallop of the posterior mitral leaflet. Double-orifice mitral valve was undetectable preoperatively. Five months after the onset of symptoms, surgical treatment was performed.

Through a median sternotomy, cardiopulmonary bypass with moderate hypothermia (28°C) was instituted. After induction of cardiac arrest, the left atrial cavity was exposed through a superior transseptal approach. On inspection, the mitral valve was found to have two orifices, with a larger orifice located anterolaterally and a smaller orifice located posteromedially (Fig 1). From the operator's view point, the larger orifice was left and the smaller orifice was right. They were separated by a fibromuscular bridge, which was noted to be leaflet tissue supported by chordae tendineae when the bridge was floated in saline solution. Each valve had a single circular leaflet, and three papillary muscles (anterolateral, middle, and posteromedial) were clarified. Anterolateral (left) and posteromedial (right) valve leaflets were supported by chordae originating from two separate branches of anterolateral and middle papillary muscles and middle and posteromedial papillary muscles, respectively. Two torn chordae connecting to the posteromedial scallop of the right valve were found, and their remnants were identified on the posteromedial papillary muscle. There were not torn or elongated chordae or prolapsed leaflets in other scallops of the right valve and any scallops of the left valve.

View larger version (110K): [in this window] [in a new window]   Fig 1.. Intraoperative findings of double orifice mitral valve. (a) The mitral valve was found to have two orifices with a larger orifice located anterolaterally and a smaller orifice located posteromedially. From the operator's viewpoint, the larger orifice was left and the smaller orifice was right. They were separated by a fibromuscular bridge, which was noted to contain leaflet tissue (arrow). (b) Two torn chordae connecting to the posteromedial scallop of the right valve were found. There were not torn or elongated chordae or prolapsed leaflets in other scallops of the right valve and any scallops of the left valve. Two pairs of CV-4 polytetrafluoroethylene grafts were used for replacement of the two torn chordae.

Postoperative recovery was uneventful. She was reviewed and has been well for 3 years after the operation. Residual MR was grade 1/4 on both left ventricular angiography and echocardiography. No regurgitant systolic murmur was audible at the apex, and recent transsternal echocardiography showed trivial MR, grade 1/4.

	Comment

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Double-orifice mitral valve is usually associated with cardiac malformations such as ventricular septal defect, atrial septal defect, Ebstein's anomaly, patent ductus arteriosus, and, most commonly, ECD. Elfenbein and Palplanus [7] reported that 13/39 cases of DOMV (33%) were associated with ECD, and Lee and associates [6] reported that 23/25 cases of DOMV (92%) were associated with ECD. On the other hand, the incidence of DOMV in cases of ECD was reported to be 4.8% (25/581 cases) by Lee and associates [6] and about 5% by Rosenberg and Roberts [5]. Some reports stated the classification of DOMV [7–9]. In their reports, Elfenbein and Palplanus classified the following three types: First, the accessory orifice is in the anterior mitral leaflet as commonly observed in ECD with DOMV [6, 7]. Second, the accessory orifice is in the posterior mitral leaflet. Third, the mitral valve is divided by bridging tissue between the anterior and posterior mitral leaflets. Including the present case, most cases of isolated DOMV were classified as the third type [10].

Most cases of DOMV were diagnosed intraoperatively. Recent progress in echocardiography provides more detailed information about cardiac anatomy, and preoperative diagnosis of DOMV in some cases [11, 12]. In the present case, DOMV was diagnosed intraoperatively and could not be diagnosed preoperatively. However, both postoperative transesophageal and transsternal echocardiographies could describe the morphology of DOMV. Thus, it seems possible to make a precise diagnosis of DOMV by suspecting mitral valve anomalies in preoperative echocardiography.

Three strategies have been adopted in the correction of DOMV: major valve repair, cleft suture, and valve replacement. When DOMV occurs in a functional and asymptomatic valve, it should not be touched. In ECD patients with no regurgitation from the DOMV, cleft suture alone generally makes it possible to correct valve regurgitation. In the first patient to undergo surgical repair, the bridging tissue was divided and cleft leaflet was sutured [13]. In this patient, valve repair was successful, but, unfortunately, the success has not been repeated in others [6, 9]. Amano and Suzuki [12] performed division of the fibrous bar and valve reconstruction by cleft suture and leaflet expansion. Their leaflet expansion technique involved the suture of a piece of glutaraldehyde-treated homopericardium to the margin of the anterior mitral leaflet to increase the size of the leaflet to make the valve competent. Because the bridging tissue between the anterior and posterior mitral leaflets is supported by chordae tendineae, which is responsible for keeping the valve competent, division of the bridging leaflet might make repair possible in a few cases of DOMV. As Bano-Rodrigo and associates [14] stated that the tissue bridge is responsible for keeping the valve competent, we believe the bridging leaflet should not be divided.

In the present case, DOMV was isolated and not associated with ECD. Mitral regurgitation was caused by two torn chordae, the prolapsed lesion of the posteromedial scallop was not extensive, and the mitral annulus was not enlarged. Regurgitant mitral valve might be able to be successfully repaired by the method of chordal transfer also [15]. This alternative method has been performed successfully in some cases of mitral valve repair. In extensive or complicated prolapsed mitral valve, however, repair by chordal transfer is rarely successful. On the other hand, the method of chordal replacement basically consists of the same technique except for the difficulty to determine the length of the artificial chordae, and can be applied to any types of mitral prolapse. The artificial chordae just replace torn chordae and other tissue is intact. The use of polytetrafluoroethylene (namely, CV-4 or CV-5 Gore-Tex; W.L. Gore & Associates, Flagstaff, AZ) artificial chordae enabled mitral valve repair. Actually, we have successfully repaired diffuse mitral valve prolapse by extended use of artificial chordae [16]. In the present case with two mitral orifices, we thought it very important to preserve the very fine relationship among leaflet tissue, bridging leaflet, chordae, and papillary muscles. Thus, we accepted a method with replacement of artificial chordae. As a result, our patient could undergo successful valve repair.

Mitral valve replacement has also been reported for patients with DOMV [17]. Valve replacement as a salvage procedure has also been reported [9]. Because superiority of valve repair to valve replacement is generally approved, we should attempt to perform valve repair for MR with DOMV.

	Footnotes

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Address reprint requests to Dr Tomita, Department of Cardiovascular Surgery, Faculty of Medicine, Kyushu University, Fukuoka 812-82, Japan (e-mail:tomita{at}heart.med.kyushu-u.ac.jp).

	References

Top Footnotes Abstract Introduction Comment References

 

1. Warnes C, Somerville J. Double mitral valve orifice in atrioventricular defects. Br Heart J 1983;49:59–64.[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): Yukihiro Tomita Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Tomita, Y. Articles by Tominaga, R. Search for Related Content PubMed PubMed Citation Articles by Tomita, Y. Articles by Tominaga, R.