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Ann Thorac Surg 2000;69:25-29
© 2000 The Society of Thoracic Surgeons

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Original Articles

Repair of anterior leaflet mitral valve prolapse: chordal replacement versus chordal shortening

^a Division of Cardiovascular Surgery, Mayo Clinic and Mayo Foundation, Rochester, Minnesota, USA

Address reprint requests to Dr Schaff, Division of Cardiovascular Surgery, Mayo Clinic and Mayo Foundation, 200 First St SW, Rochester, MN 55905
e-mail: schaff{at}mayo.edu

Presented at the Thirty-fifth Annual Meeting of The Society of Thoracic Surgeons, San Antonio, TX, Jan 25–27, 1999.

	Abstract

Top Abstract Introduction Patients and methods Results Comment References

 
Background. To determine the optimal method of repair for severe, segmental anterior leaflet prolapse, we analyzed outcome of 121 patients who underwent chordal shortening (n = 46) and chordal replacement (n = 75) from 1988 to 1996.

Methods. Chordae were replaced with expanded polytetrafluoroethylene sutures. Patients had an annuloplasty with either chordal replacement or shortening. Follow-up was 100% complete (mean, 3.7 years).

Results. Mean age was 62.1 years, 86 were men, and 60 patients had isolated valve repair. There was one hospital death and 14 late deaths for a 5-year actuarial survival of 86.4% ± 4.5%. Sixteen patients underwent reoperation, 5 in the replacement group and 11 in the shortening group. Mechanism of valve failure in the replacement group was native chordae rupture (n = 4) and neochordae dehiscence (n = 1). With chordal shortening, repair failure was attributed to rupture of shortened chordae (n = 8), leaflet prolapse with and without annuloplasty ring dehiscence (n = 2), and native chordae elongation (n = 1). Risk of reoperation because of repair failure at 3.5 years was 1.4% in the chordal replacement group and 14.8% in the chordal shortening group (p = 0.02).

Conclusions. Chordal replacement is superior to chordal shortening, providing a predictable method for correction of mitral regurgitation with a low incidence of reoperation.

	Introduction

Top Abstract Introduction Patients and methods Results Comment References

 
Valve repair for correction of mitral regurgitation is widely practiced and is generally considered the preferred procedure for patients with degenerative mitral valve disease [1–3]. The most common cause of degenerative mitral valve regurgitation is floppy (myxomatous) valve with segmental prolapse of the posterior leaflet [4], and posterior leaflet repair by partial excision or plication is highly reproducible and durable [5–7]. Correction of anterior leaflet prolapse, which occurs in approximately one third of cases [8], can be more difficult than posterior leaflet repair; redundancy of the posterior leaflet lends itself to plication or segmental excision, but prolapsing portions of the anterior leaflet are often not redundant nor amenable to excision. Poor results after anterior leaflet resections have led to a variety of techniques including chordal transposition, chordal shortening, and chordal replacement [9–11].

Replacement or reinforcement of chordae tendineae using expanded polytetrafluoroethylene (ePTFE) was introduced clinically in 1985 [10], but there are few studies comparing chordal replacement versus other accepted techniques for correction of anterior leaflet prolapse [12]. This report analyzes our experience with correction of anterior leaflet prolapse using chordal replacement with ePTFE in comparison with chordal shortening.

	Patients and methods

Top Abstract Introduction Patients and methods Results Comment References

 
Between September 1988 and September 1996, 975 adult (18 years or older) patients underwent mitral valve repair at our clinic. In 334 patients, prolapse of the anterior mitral valve leaflet was a major cause of regurgitation. It has been our policy to reserve the more complex methods of anterior leaflet repair, which are the subject of this report, for those patients who have marked segmental prolapse as is often encountered with ruptured chordae tendineae; lesser degrees of anterior leaflet prolapse are managed by annuloplasty alone or, rarely, by leaflet plication plus annuloplasty (Fig 1).

View larger version (17K): [in this window] [in a new window]   Fig 1. Distribution of anterior leaflet repairs. A total of 975 mitral valve repairs were performed during the study period, and 334 (34%) involved repair of the anterior leaflet.

View larger version (38K): [in this window] [in a new window]   Fig 2. Illustration of chordal replacement with a pledgeted expanded polytetrafluoroethylene (ePTFE) suture to the free margin of the anterior leaflet (AML).

Patients who also had segmental prolapse of the posterior leaflet usually have triangular resection or plication of that portion. In both chordal replacement and chordal shortening groups, leaflet repairs were supplemented by ring annuloplasty, most often limited to the posterior annulus [14].

Adequacy of repair was assessed during cardiotomy by filling the left ventricle with saline, and intraoperative transesophogeal echocardiography was used in all patients [15].

Mitral valve reconstruction was combined with another procedure in 61 patients (50%); 35 patients (29%) had coronary artery revascularization, and 4 (3%) had closure of atrial septal defect (Table 1). All patients were anticoagulated with warfarin sodium to maintain an international normalized ratio of 2.5 for 6 weeks postoperatively; patients whose rhythm was atrial fibrillation were continued on systemic anticoagulation indefinitely.

Follow-up was 100% complete at an average of 3.7 years; longest follow-up extended to 10 years. A total of 441 patient-years of follow-up were available for analysis. Status of patients was determined by hospital record, follow-up questionnaires, or contact with local physicians. Late postoperative echocardiograms were obtained in 66 (55%) of the 120 patients surviving hospitalization.

Survival and survivorship free of reoperation were estimated using the Kaplan-Meier method with 95% confidence intervals [16]; occurrence of reoperation among hospital survivors is expressed as a cumulative risk (100-survivorship free of reoperation), and we analyzed overall risk of reoperation as well as risk of reoperation caused by failure of the initial anterior leaflet repair. Survival curves were compared with the log-rank test. The effect of continuous variables on survival and the relationships of risk factors to survival were analyzed with the Cox proportional hazard model.

	Results

Top Abstract Introduction Patients and methods Results Comment References

 
The one hospital death (0.8%) occurred in a patient who had mitral valve repair with chordal replacement; this patient had normal mitral valve function but experienced hepatic failure and sepsis. Nonfatal complications included need for prolonged (> 48 hours) mechanical ventilation in 4 patients, infections (pneumonia or wound) in 4 patients, exploration for bleeding in 2 patients, and permanent pacemaker implantation for sinus node dysfunction after a maze procedure in 1 patient; 1 patient had a stroke.

There have been 14 late deaths; 11 were cardiac in nature or sudden, and 3 were due to other causes. None of the late cardiac deaths were related to residual mitral valve regurgitation. Overall survival (actuarial) is 86.4% ± 4.5% at 5 years, and there was no significant difference in survival between the groups having chordal shortening or chordal replacement. There were no late anticoagulant-related complications.

Sixteen patients underwent reoperation for recurrent mitral regurgitation, 5 in the chordal replacement group (mean, 0.9 ± 0.7 years postoperatively) and 11 in the chordal shortening group (mean, 2.6 ± 2.5 years postoperatively) (Fig 3A). All patients survived the second procedure. At reoperation, 12 patients (75%) had valve replacement with a mechanical prosthesis, and 4 (25%) had valve re-repair. Among the 11 patients with shortened chordae who had reoperation, 8 were found to have rupture of chordae at the papillary muscle head, 2 had leaflet prolapse and dehiscence of an annuloplasty ring, and 1 patient was found to have further elongation of native chordae.

View larger version (22K): [in this window] [in a new window]   Fig 3. (A) Cumulative risks of reoperation caused by mitral valve regurgitation from all causes. (B) Cumulative risks of reoperation caused by failure of the initial anterior leaflet repair. At 3.5 years, risk of reoperation is 1.4% after chordal replacement and 14.8% after chordal shortening (p = 0.025).

On univariate analysis, only chordal shortening and female sex were predictors of reoperation, but there were too few events to permit multivariate modeling. Among patients not having reoperation, late echocardiograms were available in 63 patients, and estimated degree of residual mitral valve regurgitation (0 to 4+) was similar (1.1 versus 1.2) for patients having chordal replacement and chordal shortening.

	Comment

Top Abstract Introduction Patients and methods Results Comment References

 
Repair of mitral valve regurgitation yields better results than prosthetic replacement with lower operative mortality, better survival, fewer thromboembolic complications, and better preservation of ventricular function [1, 3, 17]. Indeed, data suggest that even asymptomatic patients with severe mitral valve regurgitation caused by flail leaflets should be considered for operation [18]. When mitral valve regurgitation is caused by prolapse of an isolated segment of the posterior leaflet and there is little or no calcification of the leaflets or annulus, repair is possible in more than 95% of patients with very low risk.

Some clinicians are conservative, however, in advising operation for repair of mitral regurgitation caused by prolapse of the anterior leaflet because prosthetic replacement may be necessary more often than with posterior leaflet repair and because late results of anterior leaflet repair may not be as durable as repair of the posterior leaflet. In a report by Kay and colleagues [19], valve repair was undertaken in only 2 of 17 patients with prolapse of the central portion of the anterior leaflet. Although our review did not address in detail the predictability of anterior leaflet repair, we are aware of only 3 patients who had operation during the study interval in whom planned anterior leaflet repair was abandoned for prosthetic replacement.

Our experience is similar to others in that anterior leaflet prolapse contributed to mitral valve regurgitation in approximately one third of patients undergoing mitral valve repair (Fig 1) [8]. When regurgitation is caused by bileaflet prolapse or when anterior leaflet prolapses diffusely over a broad area, valve competence can almost always be restored with posterior annuloplasty (with or without posterior leaflet repair). Prolapse of a segment of the anterior leaflet adjacent to a commissure is easily repaired by plicating the anterior and posterior leaflets at the commissure. These simple methods have proven satisfactory in managing 68% of patients with anterior leaflet prolapse having valve repair at our institution.

In contrast, with severe segmental prolapse of the central portion of the anterior leaflet, direct leaflet repair is necessary, and a variety of methods have been used, including chordal shortening [20], chordal transfer [9, 11], insertion of neochordae using pericardium [21] or ePTFE [13], and, more recently, suture apposition of the anterior and posterior leaflets as described by Maisano and associates [22]. We have preferred replacement or reinforcement of chordae with ePTFE sutures because the method is relatively simple and is easily learned. The results of this review suggest that chordal replacement may be more durable than chordal shortening.

Elongated chordae are, by definition, structurally weakened, and it is not surprising that these structures may rupture late postoperatively. Late failure of anterior leaflet repair by chordal shortening has been studied by Smedira and associates [9], who reported a 26% risk of reoperation 5 years postoperatively compared with only 4% after repair with chordal transfer. In the present series, risk of reoperation for all causes of mitral regurgitation after chordal shortening was 21% at 5 years, and 8 of 11 patients had rupture of chordae at the repair site. We have used the technique of chordal transfer only rarely. Chordal replacement has the theoretical advantage of not requiring incision or manipulation of the posterior leaflet.

There are several advantages to use of ePTFE suture for chordal replacement. Properly inserted, both 4-0 and 5-0 ePTFE sutures restore stress on the valve leaflet to a normal range [23]. Long-term studies in experimental animals and in humans show that ePTFE chordae do not shrink or stiffen; indeed, these artificial chordae become covered by a fibrosis and intima simulating true chordae [13, 24]. We have not encountered an instance of suture breakage, and the only failure resulted from the ePTFE suture pulling through its papillary muscle insertion. It may be important to note that this patient had severe calcification of the posterior mitral valve annulus and was the only patient in the series whose repair was not supplemented by annuloplasty.

Identification of female sex as a risk factor for reoperation was unexpected. There were too few late events to allow multivariate modeling, and it is possible that sex is not independent of method of repair. Still, this issue should be evaluated in subsequent studies having larger numbers of patients with longer follow-up.

The principal limitation of our study is that it is retrospective and nonrandomized. Nevertheless, our findings are consistent with other reviews of outcome of chordal shortening and chordal replacement and has the advantage of being a comparative analysis with consistent review from one center. In our experience, repair of severe segmental anterior leaflet prolapse with ePTFE chordae is predictable, safe, and durable over intermediate-term follow-up.

	Acknowledgments

 
The authors thank Betty Anderson and the Department of Biostatistics for their statistical and administrative support.

	Footnotes

 
This article has been selected for the open discussion forum on the STS Web site: http://www.sts.org/section/atsdiscussion/

	References

Top Abstract Introduction Patients and methods Results Comment References

 

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This Article Abstract Full Text (PDF) Online Discussion 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): Michael R. Phillips Richard C. Daly Hartzell V. Schaff Joseph A. Dearani Charles J. Mullany Thomas A. Orszulak Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Phillips, M. R. Articles by Orszulak, T. A. Search for Related Content PubMed PubMed Citation Articles by Phillips, M. R. Articles by Orszulak, T. A.