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Ann Thorac Surg 2001;71:1377-1378
© 2001 The Society of Thoracic Surgeons

How to do it

Artificial mitral valve chordae replacement made simple

David H. Adams, MDa, Alexander Kadner, MDa, Raymond H. Chen, MD, PhDa

a Division of Cardiac Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA

Accepted for publication June 6, 2000.

Address reprint request to Dr Adams, Division of Cardiac Surgery, 75 Francis St, Brigham and Women’s Hospital, Boston, MA 02115
e-mail: dadams{at}partners.org


   Abstract
Top
 Abstract
Introduction
 Technique
 Comment
 References
 
Mitral valve repair techniques are now widely applied in patients with myxomatous valve disease. The use of artificial chords to achieve correct height adjustment of the prolapsing anterior leaflet segment can often be challenging. We describe a simple method of artificial chord reconstruction performed after annuloplasty, which allows for easy identification of functional prolapse and accurate chordal height adjustment.


   Introduction
Top
 Abstract
 Introduction
Technique
 Comment
 References
 
Mitral valve repair techniques are now widely applied in patients with myxomatous valve disease. Posterior leaflet quadrangular resection, sliding valvuloplasty, and remodeling annuloplasty are all procedures performed routinely in many centers. Anterior leaflet prolapse from chordal elongation or rupture is less common and considered an indication for valve replacement in less experienced centers. Corrective techniques including chordal transposition or placement of artificial chordae present special challenges related predominantly to achieving correct height adjustment of the prolapsing anterior leaflet segment. Previously reported artificial chordoplasty techniques routinely described adjusting the height of the anterior leaflet to match the nonprolapsing reference leaflet segment (typically P1) before remodeling annuloplasty [1]. We found this geometric approach to be challenging at times, because poor leaflet coaptation of nonprolapsing segments impeded saline testing of valve competency, which is very useful in confirming functionally significant valve prolapse. We describe a simple functional method of artificial chord reconstruction performed after annuloplasty that allows for easy identification and correction of mitral leaflet prolapse.


   Technique
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 Abstract
 Introduction
 Technique
Comment
 References
 
Placement of one or more 4-0 Gore-Tex sutures (W.L. Gore & Associates, Flagstaff, AZ) into the head of the papillary muscle is easy to perform before remodeling annuloplasty. Papillary muscle exposure is particularly enhanced after quadrangular posterior leaflet resection (Fig 1a). We prefer a simple suture technique without mattress or pledgets. The Gore-Tex suture is now left aside while the leaflet reconstruction is performed. Before annuloplasty poor leaflet apposition is present in all leaflet segments with saline testing and segmental anterior leaflet prolapse is best identified by height comparison with a normal reference point (Fig 1b). After ring annuloplasty symmetric leaflet apposition limits leaflet incompetence to the prolapsing anterior leaflet segment (Fig 1c). Now both arms of the previously placed Gore-Tex suture are passed through the margin of the prolapsing leaflet segment (Fig 1d). Passing the suture through the free edge of the cusp twice [2] as well as starting with a surgeon’s knot are useful techniques to prevent overaggressive sliding of knots when tying the Gore-Tex suture. Optimal chordal height is achieved by intermittently testing valve competency with ventricular saline injections. Valve competency after chordoplasty results from correction of prolapse resulting in a symmetric line of coaptation (Fig 1e).



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  		Fig 1. (a) Placement of one or more simple Gore-Tex sutures in the papillary muscle head is easy to perform after posterior leaflet resection because of enhanced exposure. (b) Typical appearance of a myxomatous mitral valve after posterior leaflet quadrangular resection and sliding valvuloplasty. Poor leaflet apposition is present in all leaflet segments, and segmental anterior leaflet prolapse can be localized only by height comparison with the normal reference point (usually P1). (c) After ring annuloplasty symmetric leaflet apposition limits valve incompetence to the prolapsing anterior leaflet segment. (d) After annuloplasty both arms of the Gore-Tex suture are passed through the margin of the prolapsing segment. Optimal artificial chord height is determined by intermittently testing valve competency by injecting saline into the ventricle. (e) Completed repair with artificial chord in place. A symmetric line of apposition results in valve competence.

 

   Comment
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 Abstract
 Introduction
 Technique
 Comment
References
 
The use of Gore-Tex sutures for chordal reconstruction greatly facilitates correction of anterior leaflet prolapse in the setting of severe myxomatous mitral valve degeneration. Several reports have previously addressed the technical challenges associated with this technique, including correct determination of chordal height as well as preventing Gore-Tex knot slipping [2–4]. Kasegawa and colleagues [5] have previously described chordal height adjustment after ring annuloplasty. However, we found the use of small tourniquets cumbersome and believe that our technique will simplify the performance of Gore-Tex chordoplasty by less experienced surgeons.


   References
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 Abstract
 Introduction
 Technique
 Comment
 References
 

  1. Carpentier A. Cardiac valve surgery—the "French Correction". J Thorac Cardiovasc Surgery 1983;86:323-337.[Medline]
  2. David T.E., Bos J., Rakowski H. Mitral valve repair by replacement of chordae tendineae with polytetrafluoroethylene sutures. J Thorac Cardiovasc Surg 1991;101:495-501.[Abstract]
  3. Zussa C., Polesel E., Rocco F., Galloni M., Frater R.W., Valfre C. Surgical technique for artificial mitral chordae implantation. J Card Surg 1991;6:432-438.[Medline]
  4. Frater R.W., Vetter H.O., Zussa C., Dahm M. Chordal replacement in mitral valve repair. Circulation 1990;82:IV125-IV130.
  5. 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/Free Full Text]

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