Ann Thorac Surg 2005;79:1064-1065
© 2005 The Society of Thoracic Surgeons
How to do it
A New Device for Ensuring the Correct Length of Artificial Chordae in Mitral Valvuloplasty
Yoshiro Matsui, MDa,*,
Yasuhisa Fukada, MDa,
Yuji Naito, MDa,
Shigeyuki Sasaki, MDb,
Keishu Yasuda, MDc
a Department of Cardiovascular Surgery, NTT East Corporation Sapporo Hospital, Sapporo, Japan
b Division of Medical Sciences, Health Science University of Hokkaido, Ishikari-Tobetsu, Japan
c Department of Cardiovascular Surgery, Hokkaido University of Medicine, Sapporo, Japan
Accepted for publication November 25, 2003.
* Address reprint requests to Dr Matsui, Department of Cardiovascular Surgery, Ikegami General Hospital Heart Center, 1-19,6-chome, Ikegami, Ohta-ku, Tokyo, Japan 146-8531
ymatsui-hc{at}ikegamihosp.jp
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Abstract
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Mitral valvuloplasty using Gore-Tex as artificial chordae, especially for patients with anterior leaflet prolapse, is often associated with difficulties in determining the length of artificial chordae as well as in preventing knot slipping. We describe a simple technique of using a new device that enables surgeons to easily determine the accurate length of the artificial chordae and to tie the slippery knot without sliding and damaging it.
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Introduction
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Valve repair for the correction of mitral regurgitation is now widely practiced and is generally considered the first surgical option for patients with myxomatous valve disease. Repair of the posterior leaflet is routinely performed in many centers; anterior leaflet prolapse from chordal rupture or elongation is less common and is considered an indication for valve replacement in some centers owing to the difficulty in corrective techniques. General corrective techniques include placement of artificial chordae using Gore-Tex (W.L. Gore & Associates, Flagstaff, AZ) sutures, but these techniques are often associated with difficulties in determining the length of the artificial chordae as well as in preventing the slipping of the Gore-Tex knot.
We describe a simple technique of using a new device that enables surgeons to easily determine the accurate length of the artificial chordae and to tie the slippery knot without sliding.
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Technique
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The new device (Matsuda Ika-Kogyo, Tokyo, Japan) consists of two small metallic tubes with a circular, hook-shaped distal tip made entirely of stainless steel (Fig 1). The distal tip, which is perpendicularly attached to the inner tube, is designed to hold the Gore-Tex thread at the reference point on the papillary muscle immovable. The outer tube can slide on the surface of the inner tube to measure the length from the tip of inner tube to the hook of outer tube.
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Fig 1. The new device for ensuring the correct length of artificial chordae. (Top) Lateral view of the device. (Bottom) Oblique view of the device with a circular, hook-shaped distal tip and proximal hook.
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After observation of the chordal condition, a 4-0 or 5-0 Gore-Tex mattress suture reinforced with a felt pledget is placed into the head of the papillary muscle. Both Gore-Tex suture needles are then passed through the anterior leaflet from ventricular to atrial side twice. Both arms of the suture are left untied (Fig 2, left). The required length is determined by measuring the distance between the leaflet edge and the site of implantation of the artificial chordae on the papillary muscle, using a normal valve segment adjacent to the prolapsing segment as a reference. In this procedure, the distal tip of the inner tube of the device is placed at the sutured site of artificial chordae on the papillary muscle. The proximal hook of the outer tube is slid to the edge of the adjacent nonprolapsing leaflet and then fixed at the point after reading the distance between the distal tip and proximal hook of the device. This procedure is performed for both arms of the suture. The devices are then moved to the prolapsed segments so as to hold an edge of the prolapsed leaflet with a proximal hook. As the determined distance and edge of the leaflet are fixed with the device, the Gore-Tex suture can be tied in the usual manner without knot slipping (Fig 2, right). The action of knot-tying itself works to immobilize the device by its strength. The procedure is repeated for any additional artificial chordae inserted, depending on the area of prolapsing leaflet. After removing the device, followed by saline testing, a Carpentier-Edwards annuloplasty ring is attached according to the size of the mitral annulus. Saline testing is performed again to confirm no regurgitation.
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Fig 2. A Gore-Tex (W. L. Gore & Associates, Flagstaff, AZ) mattress suture reinforced with a felt pledget is placed into the head of the papillary muscle. Both Gore-Tex suture needles are passed through the anterior leaflet from ventricular to atrial side twice (left). The required length is determined by measuring the distance between the leaflet edge and the site of implantation of the artificial chordae on the papillary muscle (right), using a normal valve segment adjacent to the prolapsing segment as a reference. The Gore-Tex suture can be tied without knot slipping. This procedure can be performed using one device unless the determined length of both arms of the suture is different.
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This technique using the new device was performed in 8 patients requiring mitral repair of the anterior leaflet prolapse. The results of intraoperative saline testing were satisfactory, and no change in the length of the artificial chordae was needed in any case. Postoperative echocardiography showed no, or trivial, mitral regurgitation in all cases.
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Comment
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Repair of mitral valve regurgitation is now widely applied in patients with myxomatous valve disease. Correction of anterior leaflet prolapse, which occurs in approximately one third of patients undergoing repair of the mitral valve, was considered more difficult than posterior leaflet repair. Since the introduction of expanded polytetrafluoroethylene (ePTFE) as a chordal substitute [1], repair of anterior leaflet prolapse has become a relatively easy and established technique with good long-term results [2]. Determining the correct length of the artificial chordae has remained somewhat problematic, however, because length varies with the site of the implantation on the papillary muscle, the angle of the needles inserted into papillary muscle to the prolapsing leaflet segments, and the features of the papillary muscle. The slippery nature of the Gore-Tex suture material and the tendency of the knot to slide have also led to some difficulty in establishing the correct length of artificial chordae. Difficulties in assessing the correct length of artificial chordae and tying the Gore-Tex suture without knot slipping have remained concerns for many surgeons, and thus various techniques have been reported [3–7].
Kasegawa and colleagues [3] described the use of a small tourniquet for fine adjustment of the length of the ePTFE suture before tying them during injection testing with saline solution. But this technique is cumbersome and is unsuitable for cases presenting with a wide prolapsing area. If the knot position is fixed and held with a curved hemostatic forceps, the suture thread may be bruised by the forceps. If the PTFE stitches are held gently, it may lead to sliding of the knot when tying the suture [3]. Many other reports describe techniques for determining the proper length of artificial chordae and tying the knot, but none of these techniques is very satisfactory and widely accepted as a standard method [4–6].
Von Oppell and colleagues [7] reported a technique of measuring the required chordal length and making a "premeasured" Gore-Tex chordal loop. They measured the distance between the leaflet edge and planned site of implantation of the artificial chordae on the papillary muscle using a ruler or measuring device. We made the device described here to refine and simplify their technique. Our technique using the new device involves premeasurement of the length of artificial chordae, similar to their method, but errors in measurement are less because the length is measured after the Gore-Tex sutures are passed through the papillary muscle and the prolapsed leaflet. In addition, our new device can be used to both measure the length of artificial chordae and fix the position of prolapsing leaflet, which enables surgeons to tie the slippery knot very easily without assistance in holding the device.
After starting to use this new device, repair of the mitral valve regurgitation has become an easy, established method even in cases where both anterior and posterior leaflet are prolapsing at the same commissure and in cases presenting with broad prolapse in the middle scallop. Our technique using the new device is simple and easy to perform and may minimize the time needed to determine the proper length of artificial chordae and to tie the knot accurately.
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References
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- Frater RWM. 10th Gore-Tex chordae anniversary. J Heart Valve Dis. 1996;5:348–351[Medline]
- David TE, 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 polytetra-fluoroethylene sutures. J Thorac Cardiovasc Surg. 1998;115:1279–1286[Abstract/Free Full Text]
- Kasegawa H, Kamata S, Hirata S, et al. Simple method for determing proper length of artificial chordae in mitral valve repair. Ann Thorac Surg. 1994;57:237–239[Abstract/Free Full Text]
- Adams DH, Kadner A, Chen RH. Artificial mitral valve chordae replacement made simple. Ann Thorac Surg. 2001;71:1377–1379[Abstract/Free Full Text]
- Sarsam MAI. Simplified technique for determing the length of artificial chodae in mitral valve repair. Ann Thorac Surg. 2002;73:1659–1660[Abstract/Free Full Text]
- Duran CM, Pekar F. Techniques for ensuring the correct length of new mitral chords. J Heart Valve Dis. 2003;12:156–161[Medline]
- Von Oppell UO, Mohr FW. Chordal replacement for both minimally invasive and conventional mitral valve surgery using prematured Gore-Tex loops. Ann Thorac Surg. 2000;70:2166–2168[Abstract/Free Full Text]
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Abstract
Introduction
