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Ann Thorac Surg 2000;70:2166-2168
© 2000 The Society of Thoracic Surgeons

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How to do it

Chordal replacement for both minimally invasive and conventional mitral valve surgery using premeasured Gore-Tex loops

^a Herzzentrum, University of Leipzig, Leipzig, Germany
^b Department of Cardiothoracic Surgery, University of Cape Town, Cape Town, South Africa

Accepted for publication May 25, 2000.

Address reprint requests to Dr von Oppell, Department of Cardiothoracic Surgery, School of Medicine, University of Cape Town, Cape Town, 7925, South Africa
e-mail: uvonopp{at}thoracic.cts.uct.ac.za

	Abstract

Top Abstract Introduction Technique Comment References

 
Part of the complexity of mitral valve chordal replacement with expanded polytetrafluoroethylene (ePTFE) sutures is determining the correct replacement chordal length and knotting the ePTFE suture without sliding the knot. We describe a technique of measuring the required chordal length and making a "premeasured" Gore-Tex chordal loop that abolishes problems of inadvertently altering chordal length during fixation. This improves the reproducibility of chordal replacement surgery, and can be used both via conventional and minimally invasive approaches.

	Introduction

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Replacement of diseased mitral valve chordae with expanded polytetrafluoroethylene (ePTFE) CV5 sutures (W. L. Gore & Associates Inc, Flagstaff, AZ) is an established technique with good long-term results [1, 2]. Various techniques have been described to assist the surgeon to establish the correct replacement chordal length, and include tying a loop at the level of the opposing leaflet [3], the use of a small tourniquet [4], or weaving the suture through the leaflet to the mitral annulus [5] and thereafter readjusting the length while the ventricle is filled under pressure.

Fixing the ePTFE suture at the correct length can also be difficult as ePTFE sutures are slippery and knots tend to slide. Techniques of tying ePTFE at the determined length include bringing each arm of the suture through the leaflet edge at least twice to create friction [2, 6], locking each side on the second pass [7], or using hemostatic clips [6] or forceps [4] to temporarily fix the suture.

We describe a new technique of using "premeasured" ePTFE loops to replace diseased chordae that enables the surgeon to more easily determine the required length of the replacement chordae and abolish problems of inadvertently altering chordal length during fixation.

	Technique

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Chordal replacement with ePTFE sutures is usually done for prolapse of one or two segments of the anterior leaflet of the mitral valve. In the majority of patients, an adjacent normal nonprolapsing segment of either the anterior or posterior mitral leaflet will provide a reference point for the correct plane of leaflet apposition.

Surgical technique
A new custom-made ePTFE replacement chordae is made by first determining the required length, by measuring the distance between the correct plane of apposition on an adjacent nonprolapsing segment and the respective papillary muscle (Fig 1), using a ruler or measuring device (03-5409; Geister, Tuttlingen, Germany), or by transesophageal echocardiography (TEE). One to three loops, as required, of CV5 ePTFE (Gore-Tex) is then made to this "premeasured" length, using a vernier caliper or measuring device as a template (Geister), by tying a knot over a small pledget (Fig 2). The caliper arms should be narrow and the pledget relatively flat not to affect the final measured loop length or, alternatively, the loop length adjusted by the width of the caliper arms and pledget. Both ePTFE suture needles are then passed back through the pledget twice, so that the size of the knot will not alter the total length and that the pledget will provide a secure platform, once this ePTFE loop is secured to the papillary muscle (Fig 2). The needles are then passed anterior to posterior on the respective papillary muscle and tied over a second pledget (Fig 3). One now has a correct "premeasured" ePTFE loop secured to the papillary muscle.

View larger version (36K): [in this window] [in a new window]   Fig 1. A ruler or measuring device measures the distance (X), between the leaflet edge and planned site of implantation of the artificial chordae on the papillary muscle, using a normal valve segment either adjacent or on the opposite leaflet to the prolapsing segment as a reference.

View larger version (23K): [in this window] [in a new window]   Fig 2. A vernier calliper type device with narrow jaws is used as a template to make a Gore-Tex loop of the correct "premeasured" length (X). (A) The "premeasured" loop is secured by knotting over a felt pledget. (B) The two suture arms are then brought twice through the pledget so that the knot does not add further length to the "loop" when secured to the papillary muscle.

View larger version (50K): [in this window] [in a new window]   Fig 3. The "premeasured" Gore-Tex chordal loop is secured to the papillary muscle as illustrated and tied over a second pledget. The end of the loop is then secured to the atrial side of the prolapsing leaflet segment, with a second Gore-Tex suture that is knotted on the ventricular aspect of the leaflet.

Clinical experience
This technique of using "premeasured" Gore-Tex loops as chordal replacements was used in 10 consecutive patients requiring chordal shortening/replacement as part of their mitral valve repair between August and December 1999. All patients had prolapse of the anterior mitral leaflet, and 40% additionally had prolapse of posterior mitral leaflet segments. The required Gore-Tex loops varied from 11 to 27 mm, and most commonly, 20- or 22-mm lengths were used. In no patient did the Gore-Tex chordae have to be altered after insertion. All patients additionally had at least a ring annuloplasty performed as part of the corrective repair. The postrepair TEE showed no or trivial mitral regurgitation in 90% of patients, and trivial to mild in 1 patient.

Repair of anterior leaflet prolapse was successfully managed by the above technique even through a small 4- to 6-cm minimally invasive right anterior lateral thoracotomy with video assistance in 50% of these patients.

	Comment

Top Abstract Introduction Technique Comment References

 
Repair of complex mitral valve prolapse usually requires more than one corrective measure. The standard maneuver of correcting prolapse of the posterior mitral leaflet is by quadrangular resection of the prolapsing segment with or without an additional sliding leaflet technique. Associated annular dilatation is usually corrected by a ring annuloplasty. Prolapse of the anterior mitral leaflet has been corrected by triangular leaflet resection, shortening of papillary muscles, chordal shortening, and transposition or replacement techniques. Since the introduction of ePTFE as a chordal substitute in 1985 [1], this has become the preferable technique used by many surgeons with excellent long-term durability [2, 8]. The CV 5 Gore-Tex suture retains flexibility similar to a native chordae and has a breaking strength greater than normal chordae [1], and replaces diseased chordae that could potentially rupture or elongate again in the future. Difficulties of assessing and tying the Gore-Tex chordae at the correct length have remained a concern for many surgeons.

The ability to perform complex mitral valve repairs through minimally invasive video-assisted approaches has been questioned or deemed to be impossible. As such, it is important to develop new techniques that facilitate and improve these endoscopic techniques allowing predictable outcomes even in more complex repairs.

This method of making a "premeasured" Gore-Tex chordal loop assists in making chordal replacement less subjective. The addition of an annuloplasty further increases the width of leaflet apposition, and therefore, if in doubt, erring on the side of making the loop slightly shorter or implanting the loop up to 5 mm further down the papillary muscle is recommended. Furthermore, if more than one chordae is required in any segment or adjacent segment, the "premeasured" Gore-Tex chordae can be made with additional loops, further simplifying multiple chordal replacements.

The use of pledgets or knots on the atrial side of a leaflet or multiple passes through the free edge frequently results in some distortion of the leaflet in the "appositional zone." In contrast, securing the loop to the atrial surface of the leaflet with knotting on the ventricular side as we have described results in a curved nondistorted free edge of the leaflet similar to a normal native valve.

This chordal replacement technique can be used through both conventional and minimally invasive approaches to the mitral valve and, in our opinion, simplifies chordal replacement through the latter.

	References

Top Abstract Introduction Technique Comment References

 

1. Frater R.W.M. 10th Goretex Chorda Anniversary. J Heart Valve Dis 1996;5:348-351.[Medline]
2. David T.E., Omran A., Armstrong S., Sun Z., Ivanov J. Long-term results of mitral valve repair for myxomatous disease with and without chordal replacement with expanded polytetrafluoroethylene sutures. J Thorac Cardiovasc Surg 1998;115:1279-1286.[Abstract/Free Full Text]
3. Matsumoto T., Kado H., Masuda M., et al. Clinical results of mitral valve repair by reconstructing artificial chordae tendineae in children. J Thorac Cardiovasc Surg 1999;118:94-98.[Abstract/Free Full Text]
4. Kasegawa H., Kamata S., Hirata S., et al. Simple method for determining proper length of artificial chordae in mitral valve repair. Ann Thorac Surg 1994;57:237-239.[Abstract]
5. Revuelta J., Garcia-Rinaldi R., Gaite L., Val F., Garijo F. Generation of chordae tendineae with polytetrafluoroethylene stents: results of mitral valve chordal replacement in sheep. J Thorac Cardiovasc Surg 1989;97:98-103.[Abstract]
6. Zussa C., Frater R.W.M., Polesel E., Galoni M., Valfré C. Artificial mitral valve chordae: experimental and clinical experience. Ann Thorac Surg 1990;50:367-373.[Abstract]
7. Sintek C.F., Khonsari S. Use of extended polytetrafluoroethylene (ePTFE) chordae to re-establish annular-papillary connection after mitral valve excision. J Heart Valve Dis 1996;5:362-364.[Medline]
8. David T.E., Armstrong S., Sun Z. Replacement of chordae tendineae with Gore-Tex sutures: a ten-year experience. J Heart Valve Dis 1996;5:352-355.[Medline]

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