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Ann Thorac Surg 2002;73:1689-1690
© 2002 The Society of Thoracic Surgeons

Correspondence

Second order anterior mitral leaflets play a role in preventing systolic anterior motion

Jean-François Obadia, MD, PhDa, Marc Janier, MD, PhDa

a Cardiothoracic Surgery Unit, Hôpital Cardiothoracique, BP Lyon-Monchat, 69394 Lyon Cedex 03, France

e-mail: jf.o{at}chu-lyon.fr

To the Editor

We found the recent article by Timek and colleagues very interesting [1]. Actually, Miller and colleagues have a large experience with a radiopaque marker technique in an ovine model [2], which is a very elegant way to study the motion of the different mitral valve components during the cardiac cycle. They compare their results with our results [3] obtained with a different experimental model using an isolated working pig heart preparation. In both articles, it is concluded that the second order chordae (SOC) have no effect on valve competence since no leak appeared in both models after they were cut and there was no doubt about this. Conversely, in our isolated pig heart model, left ventricular function was decreased after cutting the SOC but this was not confirmed by the radiomarker model where no hemodynamic changes were found. Despite this discrepancy, they conclude that SOC has a negligible role and that they can be transferred with no risk to the free edge of the anterior leaflet during mitral valve repair. In this letter, we do not want to intiate a tedious discussion about the respective advantages of the two models since, in our practice, we sometimes use SOC transfer for repairing anterior leaflet prolapse despite possible marginal hemodynamic impairment. Nevertheless, there is a striking difference in thickness between the primary and secondary chordae which suggests that the latter plays the principal support role during left ventricular contraction. Furthermore, there is a function devoted to the SOC which has not been discussed by Timek and associates. This function appeared clearly when we introduced a videoscope inside the left ventricle through the apex of our isolated pig heart preparation (work not published). During diastole, the SOC limit the opening of the anterior leaflet (Fig 1) and prevent it going too close to the septum, so that at the beginning of systole, the anterior leaflet has no risk of being pushed into the left outflow tract. This is what we could call an anti-systolic anterior motion (anti-SAM) function. This underestimated function can also be seen very simply on echography in some of our patients. Finally, we can accept Timek and colleagues’ conclusion in many circumstances, but not when there is a risk of SAM (eg, acute mitro-aortic angle, sub-aortic hypertrophic septum); in such situations, other techniques like "flip over" transferring chords from the posterior leaflet are preferred.



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  		Fig 1. In systole, the axis of the forces runs through a line including the papillary muscle, the secondary order chordae (SOC), the proximal part of the anterior leaflet, and the subaortic curtain. In diastole, the SOC limit the outward motion of the anterior leaflet, which in turn limits the risk of systolic anterior motion during the following systole. (Ao = aorta; LA = left atrium; LV = left ventricle.)

 
References

  1. Timek T.A., Nielsen S.L., Green G.R., et al. Influence of anterior mitral leaflet second-order chordae on leaflet dynamics and valve competence. Ann Thorac Surg 2001;72:535-541.[Abstract/Free Full Text]
  2. Glasson J.R., Komeda M., Daughters G.T., et al. Most ovine mitral annular three-dimensional size reduction occurs before ventricular systole and is abolished with ventricular pacing. Circulation 1997;96(Suppl 2):115.
  3. Obadia J.F., Casali C., Chassignolle J.F., et al. Mitral subvalvular apparatus: different functions of primary and secondary chordae. Circulation 1997;96:3124-3128.[Abstract/Free Full Text]



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