Ann Thorac Surg 2007;83:1902-1903
© 2007 The Society of Thoracic Surgeons
How To Do It
Simple, Safe and Easy Technique to Ensure the Correct Length of Artificial Chordae in Mitral Valve Repair
Khalil Fattouch, MD, PhD*,
Giuseppe Bianco, MD, PhD,
Fabrizio Sbraga, MD,
Roberta Sampognaro, MD,
Giovanni Ruvolo, MD
Unit of Cardiac Surgery, University of Palermo, Palermo, Italy
Accepted for publication June 1, 2006.
* Address correspondence to Dr Fattouch, University of Palermo, Cardiac Surgery Department, Via Liborio Giuffrè 5, Palermo, 90100 Italy (Email: khalilfattouch{at}hotmail.com).
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Abstract
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Replacement of diseased chordae with Gore-Tex sutures (W. L. Gore & Assoc, Flagstaff, AZ) in patients with degenerative mitral valve insufficiency has become a standard technique used by surgeons in mitral valve repair with good long-term results. Nevertheless, determining the correct length of the artificial chordae has remained problematic. Although various procedures have been previously published, in this article we describe our approach used to achieve an accurate chordal height adjustment.
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Introduction
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Today, mitral valve repair is the first choice for the surgical treatment of mitral valve regurgitation [1]. In patients with degenerative mitral valve disease, one of the mechanisms implicated in mitral regurgitation is leaflet prolapse or flail due to chordal elongation or rupture. The common technique used in repairing leaflet prolapse is to replace native chordae with artificial chordae (polytetrafluoroethylene [Gore-Tex, W. L. Gore & Assoc, Flagstaff, AZ]), correcting prolapse, and restoring a good coaptation surface [2]. This technique seems to be easy and simple, but it is often challenging for the surgeon, who works on an empty nonbeating heart due to difficulties in determining the correct length of artificial chordae and ensuring a normal leaflet apposition. If the neo-chordae is too short it will result in a restricted leaflet motion, and if it is too long it will not be effective in correcting leaflet prolapse.
In this article we describe our technique used to determine the correct length of the neo-chordae.
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Technique
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The technique used to place the neo-chordae in mitral valve repair using the 5-0 Gore-Tex suture (W. L. Gore & Assoc) is first performed by placing the suture in the head of the papillary muscle using a simple suture with pledgets (Fig 1
[step 1a]). This procedure is performed before remodeling annuloplasty because the exposure of the papillary muscles at this point is easier than after annuloplasty. The prolapsing scallops are then identified and the free arms of the previously placed Gore-Tex suture are passed through the free edge of the prolapsing scallops at about 5 mm from the margin, from the ventricular to the atrial side (Fig 1 [step 1b]). A temporary edge-to-edge repair (Alfieri’s technique) is performed using a 4-0 Prolene suture (Ethicon, Somerville, NJ) [3] until a valve competency is obtained; the free edge of the prolapsing scallop of the anterior leaflet is sutured to the facing edge of the posterior leaflet, and the stitch is placed between the neo-chordae and free margin of the leaflet, being careful to avoid the anchorage of the Gore-Tex sutures (Fig 1 [step 2a]). Remodeling annuloplasty is then performed using an appropriate annular ring. A water test is performed to check valve competency (Fig 1 [step 3a]). When a satisfactory result with a good leaflet apposition is observed, the neo-chordae are tied permanently under heart loading with water (Fig 1 [step 3b]). In this way, the length of the artificial chordae matches perfectly the normal chordae present in the valve. Moreover, a correct chordal height adjustment is obtained by a normal geometric reconstruction of the mitral apparatus that has been achieved by the symmetric annular remodelling, the edge-to-edge repair, and the left ventricular filling with water. The temporary 4-0 Prolene suture (Ethicon) used for the edge-to-edge repair is then cut and removed (Fig 1 [step 4a]). Finally, both arms of the Gore-Tex sutures are passed through the free margin of the leaflet from the atrial to the ventricular side and are finally re-tied and cut (Fig 1 [step 4b]).
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Fig 1. (Step 1a) Placement of the Gore-Tex sutures (W. L. Gore & Assoc, Flagstaff, AZ) in the papillary muscle head is easy to perform before annuloplasty remodelling. (Step 1b) Identification of one or more scallops prolapse and placement of the free arms of the Gore-Tex sutures through the free edge of the prolapsed scallops. (Step 2) An edge-to-edge repair is performed to achieve a good leaflet apposition with valve competency tested with water. (Step 3a) Remodelling annuloplasty with an appropriate ring. (Step 3b) The Gore-Tex sutures were tied permanently, after ring implantation, under testing valve competency by injecting water into the left ventricle. (Step 4a) The edge-to-edge suture was cut and removed. (Step 4b) Replacement of the free arms of the Gore-Tex sutures through the free margin from atrial to ventricular side and finally tied and cut.
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This technique can be used for one or more scallops prolapse. In case of complex mitral valve anatomy with more scallops prolapse in both leaflets, 10 to 16 neo-chordae can be placed, as previously described; the prolapsing scallops and the mitral valve are closed completely using an edge-to-edge repair, keeping a small orifice at the anterolateral commissure for water injection (Fig 1 [step 2b]). The procedure is then completed as previously described. In case of patients with excessive leaflet tissue, such as in Barlow disease, the Gore-Tex sutures must be placed at about 1 cm from the free margin to obtain the shortening of the height of the leaflet (scallops A2 or P2) and ensure a large and good coaptation surface.
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Comment
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Today, the Gore-Tex suture is widely used in mitral valve repair and several techniques have been described to determine the correct length of the artificial chordae [4–7]. Moreover, the nature of the suture material and the tendency of the knot to slide have resulted in difficulty in establishing the correct length of the neo-chordae. Adams and colleagues [4] proposed a technique that consists of the placement of one or more simple Gore-Tex sutures in the papillary muscle head; after ring annuloplasty, both arms of the Gore-Tex suture are passed through the margin of the prolapsing segment and the correct artificial chordae length is determined by intermittently testing valve competency by water injection into the left ventricle.
Sarsam [5] proposed a method that consists of the placement of one or more Gore-Tex sutures in the appropriate papillary muscle. The two arms of the suture are then passed through the rough free edge of the prolapsing leaflet from the ventricular to the atrial side. The edges of the anterior and posterior leaflet are temporarily approximated by a simple suture. The Gore-Tex sutures are tied and the temporary suture is removed. In this way, the length of the new chordae obtained for the prolapsing leaflet will exactly match that of the normal leaflet.
Von Oppell and Mohr [6] described a technique of measuring the required chordal length making a pre-measured Gore-Tex chordal loop. Matsui and colleagues [7] used a new device for measuring the correct chordal length.
In this article we describe our technique used to easily determine the correct length of neo-chordae. We have used this technique in 10 patients with mitral valve regurgitation. Eight patients had isolated anterior leaflet prolapse, 6 patients had scallop A2 prolapse, and 2 patients had scallops A2 and A3 prolapse. Two patients had prolapse in both leaflets (ie, A2 and P2). In the last patients, the new chordae were placed in both leaflets (ie, 6 artificial chordae [3 sutures] in each scallop). Postoperatively, trivial mitral valve regurgitation was observed in 2 patients, and in 8 patients the valve was perfectly competent. The mean time of cardiopulmonary bypass and aortic cross clamp were 132 ± 31 minutes and 102 ± 23 minutes, respectively.
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References
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- Carpentier A. Cardiac valve surgery: the "French correction." J Thorac Cardiovasc Surg 1983;86:323-337.[Medline]
- David TE, Bos J, Rakowski H. Mitral valve repair by replacement of chordae tendinea with polytetrafluoroethylene sutures J Thorac Cardiovasc Surg 1991;101:495-501.[Abstract]
- Fucci C, Sandrelli L, Pardini A, Torracca L, Ferrari M, Alfieri O. Improved results with mitral valve repair using new surgical techniques Eur J Cardiothorac Surg 1995;9:621-626.[Abstract]
- Adams DH, Kadner A, Chen RH. Artificial mitral valve chordae replacement made simple Ann Thorac Surgery 2001;71:1377-1379.[Abstract/Free Full Text]
- Sarsam MAI. Simplified technique for determining the length of artificial chordae in mitral valve repair Ann Thorac Surg 2002;73:1659-1660.[Abstract/Free Full Text]
- Von Oppell UO, Mohr FW. Chordal replacement for both minimally invasive and conventional mitral valve surgery using pre-measured Gore-Tex loops Ann Thorac Surg 2000;70:2166-2168.[Abstract/Free Full Text]
- Matsui Y, Fukada Y, Naito Y, Sasaki S, Yasuda K. A new device for ensuring the correct length of artificial chordae in mitral valvuloplasty Ann Thorac Surg 2005;79:1064-1065.[Abstract/Free Full Text]
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Abstract
Introduction
