Ann Thorac Surg 2002;73:1659-1660
© 2002 The Society of Thoracic Surgeons
How to do it
Simplified technique for determining the length of artificial chordae in mitral valve repair
Mazin A.I. Sarsam, FRCS, FRCS (Ed), FRCS (CTh)*a
a Department of Cardiac Surgery, Royal Victoria Hospital, Belfast, Northern Ireland
Accepted for publication November 15, 2001.
* Address reprint requests to Mr Sarsam, Department of Cardiothoracic Surgery, Knightsbridge Wing, St. George’s Hospital, Blackshaw Rd, London SW17 0QT, UK
e-mail: mazin.sarsam{at}stgeorges.nhs.uk
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Abstract
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Artificial chordal replacement using polytetrafluoroethylene sutures has become an established component in the technique for mitral valve replacement with good long-term results [1, 2]. Although various techniques have been described to determine the length of the artificial chordae, this has remained somewhat problematic. A neo-chordae that is too short will, in effect, result in a restricted leaflet movement. A neo-chordae that is too long will be ineffective in controlling leaflet prolapse.
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Introduction
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In the past 2 years, we have used a simple technique whereby the length of the chordae is determined accurately and speedily.
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Technique
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The operative technique for chordal replacement was performed by passing one, or more, 5-0 suture polytetrafluoroethylene Gore-Tex (W. L. Gore & Assoc, Flagstaff, AZ) suture(s), supported by a felt pledget through the fibrous portion of the appropriate papillary muscle. The suture is left untied. The two arms of the suture were then passed once through the rough free edge of the prolapsing leaflet from the ventricular to the atrial side. In cases where the native chordae to the corresponding part of the opposing leaflet are normal, the edges of the anterior and posterior leaflet are then temporarily approximated by a simple or figure-of-eight suture, which is held by the assistant, while the surgeon ties the Gore-Tex suture, against the temporary suture (Fig 1).
Three knots are used. The Gore-Tex suture is then passed again through the edge of the leaflet from ventricular to atrial side and tied permanently. The temporary suture is then removed. In this way, the length of the chordae obtained for the prolapsing leaflet will exactly match that for the normal leaflet. The procedure is repeated for any additional chordae inserted.
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Fig 1. Anterior and posterior leaflet of the mitral valve are approximated by a temporary suture which is held upwards by the assistant, while the Gore-Tex suture is tied. Steps 1 to 3show the insertion of the suture into the leaflet.
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In cases where both anterior and posterior leaflet are prolapsing at the same commissure, the first suture is passed through one of the leaflet edges as described. The normal commissure is then used as a reference point while the first suture is tied to bring the free edge of the leaflet to the plane of the mitral valve annulus. The length of this suture is then used as the new reference point for the remaining chordae as described.
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Comment
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Since its clinical introduction in 1985 [3], chordal replacement or reinforcement using expanded polytetrafluoroethylene has become an established technique in mitral valve repair. The slippery nature of the suture material and the tendency of the knot to slide have resulted in some difficulty in establishing the length of artificial chordae. None of the established techniques are very satisfactory. These include bringing the edge of the leaflet to the level of the papillary muscle and tying the loop at the level of the opposing leaflet [4]; use of a small tornica for fine adjustment of the length of the suture before tying them during leaking test [5]; passing through the suture, through the leaflet, to the mitral annulus and then adjusting the length while the ventricle is filled [6]; and measuring the required chordal length and making a "pre-measured" Gore-Tex loop [7].
Our technique as described is simple, and the resultant new chordae exactly matches the normal chordae in length. We have used this technique in 10 patients for both anterior and posterior leaflet prolapse. The last patient required the insertion of 20 new chordae (10 sutures) using the described technique, with very satisfactory results.
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References
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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]
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Phillips M.R., Daly R.C., Schaff H.V., et al. Repair of anterior leaflet mitral valve prolapse: chordal replacement versus chordal shortening. Ann Thorac Surg 2000;69:25-29.[Abstract/Free Full Text]
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David T.E. Replacement of chordae tendineae with expanded polytetrafluoroethylene sutures. J Card Surg 1989;4:286-290.[Medline]
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Matsumoto H., 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]
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Kasegawa H., Kamata S., Hirata S., et al. Simple method for determining proper length of artificial chordae in mitral valve repair. Ann Thorac Surg 1989;97:98-103.
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Revuelta J., Garcia-Rinaldi R., Gaite L., et al. Generation of chordae tendineae with polytetrafluoroethylene stents. J Thorac Cardiovasc Surg 1989;97:98-103.[Abstract]
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Von Oppell U.O., Mohr F.W. Chordal replacement for both minimally invasive and conventional mitral valve surgery using premeasured Gore-Tex loops. Ann Thorac Surg 2000;70:2166-2168.[Abstract/Free Full Text]
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Abstract
Introduction
