Ann Thorac Surg 2006;81:375-377
© 2006 The Society of Thoracic Surgeons
How to do it
Choice of Artificial Chordae Length According to Echocardiographic Criteria
Antonio M. Calafiore, MD
*
Division of Cardiac Surgery, University of Turin, Turin, Italy
Accepted for publication August 26, 2004.
* Address correspondence to Dr Calafiore, Division of Cardiac Surgery, "S Giovanni Battista" Hospital, c.so Bramante 86, Torino, Italy. (Email: calafiore{at}unich.it).
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Abstract
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A simple way to identify artificial chordae length is reported. The distance A between the edge of the prolapsing anterior leaflet and the plane of the mitral annulus is measured during perioperative transesophageal echocardiography. When the mitral valve is exposed, the elongated chorda, corresponding to the scallop previously evaluated, is measured with a ruler and A is subtracted. This is the length of the new chorda that is measured with a ruler and tied at that level after being properly positioned.
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Introduction
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Measurement of the proper length of artificial chordae can be performed according to different techniques: measurement of a nonprolapsing chorda and manufacturing of the new chorda [1], use of a temporary suture that joins the anterior to the nonprolapsing posterior leaflet [2], use of a nonprolapsing scallop as a reference point [3, 4], and filling of the left ventricle with saline [5–7]. Because there is no universally accepted method, we report a simple way to decide chordal length based on perioperative transesophageal echocardiography.
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Technique
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During the perioperative transesophageal echocardiogram, the distance A between the border of the prolapsing portion of the anterior leaflet and the plane of the mitral annulus is measured (Fig 1). The coaptation of the mitral leaflets is located roughly 3 mm below the annular plane, but the origin of the new chorda is generally at a lower level than the chorda that will be replaced. As a consequence these two latter measures annul each other. In fact, the goal of the procedure is to avoid the anterior leaflet to prolapse in the left atrium, not to re-establish the physiologic level of coaptation; clinical experience showed that when the border of the anterior leaflet reaches the annular plane, it is not necessary to displace it downward [8].
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Fig 1. Perioperative transesophageal echocardiogram. The distance A between the edge of the prolapsing portion of the anterior leaflet and the plane of the mitral annulus is measured. In this case, A is 5 mm.
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When the mitral valve is exposed, the elongated chorda is measured with a ruler (Fig 2) and A is subtracted. The resulting figure represents the length of the new chorda.
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Fig 2. When the mitral valve is exposed, the elongated chorda is measured with a ruler. In this case, the length is 30 mm. (AL = anterior leaflet.)
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Then the 4-0 Gore-Tex (W. L. Gore & Assoc, Flagstaff, AZ) is passed through the fibrous tip of the papillary muscle and fixed. The new chorda is passed in the border of the anterior leaflet in the proper place and its final length is measured with a ruler. A mark is applied with a pen to indicate this distance and the Gore-Tex is then tied with the aid of a nerve hook (Fig 3). When more chordae are used, the procedure is not repeated, but the length of the remaining chordae is adjusted in order to maintain the anterior leaflet at the same level than the first measurement.
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Fig 3. (A) A mark is applied with a pen to indicate the length of the new chorda (30 to 5 = 25 mm). (B) The Gore-Tex suture (W. L. Gore & Assoc) is then tied at that level.
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Clinical Experience
Twenty consecutive patients with prolapse of the anterior leaflet (mainly A2, but in 9 patients more than one anterior scallop was interested) underwent chordal replacement using the technique previously described. A mean of 5.6 chordae per anterior leaflet was used. Additional mitral pathology included prolapse or rupture of the posterior leaflet in 11 patients (P2 in 3 patients, P3 in 2 patients and more than one scallop in the remaining 6 patients), with an application of 2.3 chordae per posterior leaflet. The technique was easy to apply and all the anterior leaflets showed good coaptation (Fig 4). In all the patients a posterior annuloplasty with an undersized ring, 40-mm long (SMB40, Sorin, Saluggia, Italy) was used. All the patients had an uneventful recovery and none showed residual mitral regurgitation at the discharge. After a mean follow-up of 8 ± 3 months, 18 patients showed no mitral regurgitation and 2 a regurgitant area < 1 cm2.
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Comment
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Use of artificial chordae is a useful tool to increase the possibility to perform complex mitral valve repair. The different modalities that were proposed to establish the proper length of the new chordae can be grouped in functional and anatomical.
The functional techniques evaluate the length of the new chorda filling the left ventricle with saline. Kasegawa and colleagues [5] proposed the use of a small tourniquet to progressively adjust the length of the chordae. David and colleagues distended the ventricle with saline observing where the free margin of the leaflets should coapt. Duebener and colleagues [6] and Adams and colleagues [7] used the same technique: a new chorda was passed and tied after adjustment of its length after filling the ventricle with saline.
The anatomic techniques evaluate the length of the new chordae having as a reference point a nonprolapsing scallop in front of the prolapsing one. This strategy was used by David and colleagues [4] and Matsumoto and colleagues [3]. von Oppell and Mohr [1] ingeniously made a custom-made "pre-measured" new chordae by measuring the distance between the correct plane of apposition on an adjacent nonprolapsing segment and the respective papillary muscle. This method is particularly useful in minimally invasive mitral valve repair. Sarsam [2] proposed an interesting technique in patients in which the native chordae to the corresponding part of the opposing leaflet are normal. The edges of the anterior and posterior leaflet are temporarily approximated by a temporary suture, which is held by the assistant while the surgeon ties the Gore-Tex suture against the temporary suture.
All these techniques are helpful and work properly in the great majority of patients. We focused our attention on anatomic techniques, because fixing the Gore-Tex suture at the correct length can be difficult due to knots that tend to slide. The anatomic techniques generally need to have a normal scallop in front of the prolapsing one. Sometimes this does not happen, particularly in complex mitral degenerative disease in which >2 scallops are involved. The technique we describe has the advantage to utilize objective data obtained with a simple echocardiographic evaluation, preoperative or perioperative. Other objective measurements are performed in the operating room, and the length of the new chorda is easily obtained. The length of all the other chordae is based on the length of the first one; it is not necessary to repeat any other measurement.
We think that the choice of exact measure of a new chorda is challenging for any surgeon. Having in his own armamentarium different solutions can be helpful in choosing the proper technique for the single patient.
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References
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- von Oppell UO, Mohr FW. 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]
- Sarsam MAL. Simplified technique for determining the length of artificial chordae in mitral valve repair Ann Thorac Surg 2002;73:1659-1660.[Abstract/Free Full Text]
- Matsumoto T, Kado H, Masuda M, et al. Clinical results of mitral valve by reconstructing artificial chordae tendinae in children J Thorac Cardiovasc Surg 1999;118:94-98.[Abstract/Free Full Text]
- 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 polytetrafluoroethylene sutures J Thorac Cardiovasc Surg 1998;115:1279-1286.[Abstract/Free Full Text]
- Kasegawa H, Kamata S, Hirasa S, et al. Simple method for determining proper length of artificial chordae in mitral valve repair Ann Thorac Surg 1989;97:98-103.
- Duebener LF, Wendlera O, Nikoloudakisa N, Georgb T, Friesc R, Schäfers HJ. Mitral-valve repair without annuloplasty ringsresults after repair of anterior leaflet versus posterior leaflet defects using polytetrafluoroethylene sutures for chordal replacement. Eur J Cardiothorac Surg 2000;17:206-212.[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]
- Gillinov AM, Cosgrove DM, Wahi S, et al. Is anterior leaflet repair always necessary in repair of bileaflet mitral valve prolapse? Ann Thorac Surg 1999;68:820-824.[Abstract/Free Full Text]
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Abstract
Introduction
