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Ann Thorac Surg 2001;71:1378-1379
© 2001 The Society of Thoracic Surgeons
a Division of Cardiothoracic Surgery, Department of Surgery, Hospital of the University of Pennsylvania, 4 Silverstein, 3400 Spruce St, Philadelphia, PA 19104, USA
Mitral valve repair for valvular insufficiency secondary to myxomatous valve disease has been demonstrated to be superior to mitral valve replacement in most circumstances. The functional characterization of the cause of the mitral valve insufficiency by Carpentier and the techniques he developed for its correction have proved durable. Techniques of repair such as quadrangular resection, annular plication, sliding plasty and annular remodeling using annuloplasty rings are easily learned and are in wide use. Degenerative mitral valve disease in the majority of cases involves primarily the posterior leaflet and annular dilatation. In the majority of cases where the posterior leaflet is prolapsed and the annulus is dilated, quadrangular resection alone with placement of a ring is all that is needed and can be accomplished easily in most cardiac centers. Anterior leaflet involvement is uncommon. Mild cases of anterior leaflet prolapse, associated with more pronounced posterior leaflet prolapse, generally do not need to be addressed if the primary pathology of the posterior leaflet and the dilated annulus is corrected.
Predominant anterior leaflet prolapse presents the surgeon with a more difficult problem. The classic technique, developed by Carpentier, involves chordal shortening of the elongated chord. This is done by looping the elongated chord with a monofilament suture and pulling it down into a papillary muscle trench. Though used successfully by Carpentier, this technique has several disadvantages. Accurate chordal height adjustment is difficult and must be done before the annuloplasty ring placement and saline testing. The elongated chordae are often very thin. In several experienced centers chordal shortening has been found not to be durable with easy chordal rupture leading to reoperation.
A second technique, which can be used, is the transfer of chordae from the posterior leaflet up to the prolapsing portion of the anterior leaflet. This technique can only be used if the leading edge of the posterior scallop to be transferred with its attached chords is of normal height and non–prolapsing. When combined with a small quadrangular resection, this is a reproducible technique, since the correct chordal height is already assured.
The final technique for repair of anterior leaflet prolapse is to replace the ruptured or elongated chord with a Gore-Tex (W.L. Gore & Associates, Flagstaff, AZ) suture as addressed in this paper. I feel this is the technique of choice if the posterior leaflet is also prolapsing and chordal transfer cannot be used. It has been shown superior to chordal shortening in a recent report from the Mayo Clinic where the risk of reoperation at 3
years was 1.4% with chordal replacement with Gore-Tex suture and almost 15% with chordal shortening. The use of Gore-Tex sutures to replace chordae has been shown to be safe with no increased risk of thrombo-embolic complications and is extremely durable. David and colleagues [1] reported a 10 year freedom of reoperation with chordal replacements by Gore-Tex suture at 96%. This is identical to repair without the use of Gore-Tex suture to replace chordae.
Adams and coworkers point out the biggest pitfall in use of this technique is accurate chordal height adjustment. It is very easy to tie the Gore-Tex suture down too far and actually end up with a restricted portion of the anterior leaflet. Their suggestion of leaving final adjustment of the Gore-Tex suture height to the very end is an excellent one. The final knot is tied with the ventricle filled to improve accuracy of the new chordal length.
This is a nice contribution to the repair of the anterior mitral valve leaflet. Use of this technique, as described by the authors, and the use of chordal transfer, when indicated, improve overall results of anterior leaflets repairs.
References
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