Ann Thorac Surg 2006;82:348-349
© 2006 The Society of Thoracic Surgeons
How to do it
Simple and Easy Method for Chordal Reconstruction During Mitral Valve Repair
Yasuhiro Shudo, MD,
Kazuhiro Taniguchi, PhD
*
,
Toshiki Takahashi, PhD,
Hajime Matsue, MD
Department of Cardiovascular Surgery, Japan Labour Health and Welfare Organization, Osaka Rosai Hospital, Osaka, Japan
Accepted for publication May 24, 2005.
* Address correspondence to Dr Taniguchi, Department of Cardiovascular Surgery, Japan Labour Health and Welfare Organization, Osaka Rosai Hospital, 1179-3 Nagasone, Sakai, Osaka, 591-8025 Japan (Email: yasuhiro-shudo{at}s5.dion.ne.jp).
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Abstract
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We describe a simple reproducible method for chordal replacement using expanded polytetrafluoroethylene sutures during a mitral valve repair. With this technique, fine length adjustments of the new chordae are easy to make and it is possible to tie the two ends of the suture securely without slippage.
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Introduction
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The use of expanded polytetrafluoroethylene sutures for chordal replacement is an important technique during mitral valve repair. However, surgeons often experience difficulty with achieving a correct length of the new chordae, as Frater and colleagues [1] have noted.
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Technique
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With our method, a double-armed 5-0 polytetrafluoroethylene (CV5 [Gore-Tex]) suture is passed twice through the most fibrous portion of the anterior or posterior part of the papillary muscle heads and is tied down. However, the best site for attachment of the new chordae is not always the tip of the anterior part of the papillary muscle that anchors the elongated or ruptured chordae. Multiple knots are then tied until the whole length of the knots reaches the free edges of the normal posterior and anterior leaflets (Fig 1). In this manner, the surgeon can accurately predict the correct length that is needed to hold the opposing free edges of the posterior and anterior leaflets at the same level, as well as how many knots are appropriate for the length of the new chordae. For example, 5 knots constitutes approximately 2.0 mm in length. The two arms of the suture are then passed through the thickened free edge of the prolapsed cusp from the ventricular to the atrial side, and the ends can be tied together on both sides without slippage (Fig 2).
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Fig 1. Illustration of technique used to determine the proper length of the artificial chordae. Multiple knots are made until the new chordae exactly matches the normal chordae in length.
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Fig 2. In the present method, the two arms of the suture can be tied together on the ventricular side without slippage.
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After fluid testing to confirm the competence of the valve, a Cosgrove-Edwards ring annuloplasty is performed in all cases. We have used this method in 5 patients for a localized anterior leaflet prolapse with excellent results.
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Comment
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Our modified procedure described here is easy to perform and solves the two primary problems generally encountered (ie, determining the length of the new chordae and tying the knot). The basic principles for determination of chordae length are well established [1–3], and the correct length is that which keeps the opposing free edges of the anterior and posterior leaflets parallel [1]. Kasegawa and colleagues [4] reported a technique to determine the proper length of artificial chordae using small tourniquets, in which length adjustment is made during fluid testing of the valve repair after an annuloplasty ring has been placed. Once the competence of the valve has been confirmed, the tourniquet is released and both ends of the stitches are tied. However, in practice this can be quite troublesome, particularly in cases in which simultaneous maneuvers are needed for valve repairs.
Expanded polytetrafluoroethylene sutures are slippery and difficult to tie knots without sliding, though surgeons can cope by using a traction suture, a temporarily placed vascular clip, or a clamp with rubber covered jaws. David and colleagues [2] reported a technique to pass the sutures through the thickened free edge of the cusp several times until the friction is sufficient to prevent sliding. In the present method, the knot can be securely tied down without sliding.
Our modification is simple and easy to perform, and the short-term results have been satisfactory. Furthermore, the relative technical ease has eliminated our hesitancy to perform a chordal replacement, which has led to a wider application of a prolapsing anterior leaflet. Nevertheless, long-term, follow-up studies of the functional and pathohistological changes of the new chordae are necessary.
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References
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- Frater RWM, Vetter HO, Zussa C, et al. Chordal replacement in mitral valve repair Circulation 1990;82(Suppl 4):4-125.
- Adams David H, Alexander K, Chen Raymond H. Artificial mitral valve chordae replacement made simple Ann Thorac Surg 2001;71:1377-1379.[Abstract/Free Full Text]
- Nicholas G, Raphael S, Delos M, et al. Repair of anterior leaflet prolapsechordal transfer is superior to chordal shortening. J Thorac Cardiovasc Surg 1996;112:287-292.[Abstract/Free Full Text]
- 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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Abstract
Introduction
