Ann Thorac Surg 2007;84:2127-2129. doi:10.1016/j.athoracsur.2007.04.046
© 2007 The Society of Thoracic Surgeons
How To Do It
Pre-Measured Artificial Chordae for Mitral Valve Repair
A. Marc Gillinov, MD*,
Michael K. Banbury, MD
Department of Thoracic and Cardiovascular Surgery, The Cleveland Clinic, Cleveland, Ohio
Accepted for publication April 13, 2007.
* Address correspondence to Dr Gillinov, Department of Thoracic and Cardiovascular Surgery, The Cleveland Clinic/F24, 9500 Euclid Ave, Cleveland, OH 44195 (Email: gillinom{at}ccf.org).
| Dr Gillinov discloses that he has a financial relationship with Viacor, Edwards Lifesciences, St. Jude, and Medtronic.
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Abstract
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There is growing interest in the application of artificial chordae to correct mitral valve regurgitation caused by prolapse. Application of pre-measured artificial chordae facilitates creation of chordae of appropriate length. Herein we illustrate the technique for creation of pre-measured artificial chordae, documenting neo-chordal length and number in 50 patients with anterior leaflet prolapse, highlighting the need for chordae of more than one length in 14% of patients.
There is growing interest in the use of artificial chordae for mitral valve repair [1–4]. The primary challenges with the application of e-polytetrafluoroethylene (ePTFE) chordae (Gore-Tex; W.L. Gore & Assoc, Flagstaff, AZ) include: (1) determination of chordal length and (2) fixation of chordae to the papillary muscle and leaflet in a fashion that maintains correct chordal length. In 2000, Von Oppell and Mohr addressed these concerns with their description of a technique for creation of pre-measured ePTFE chordal loops [1]. The objectives of this report are to (1) describe and illustrate the surgical technique in detail, (2) document the most common chordal lengths for creation of anterior leaflet chordae, and (3) highlight the need for chordae of more than one length in 14% of patients.
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Technique
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Valve Inspection
After review of the intraoperative transesophageal echocardiogram and surgical exposure, systematic inspection of all valve components was performed. The prolapsing segment and elongated or ruptured chordae were identified. Stay sutures were placed around normal chords on either side of the prolapsing segment; the segment of leaflet between these sutures was the region that required chordal support. Next, the papillary muscles were inspected to identify the site for chordal attachment. Visualization of the papillary muscles was facilitated by gentle retraction of a handheld retractor placed through the valve orifice. A broad-based papillary muscle beneath the area of prolapse was identified.
Chordal Length
Next, chordal length was determined. The retractor was removed and a normal chord adjacent to the area of prolapse was measured with a caliper; usually this was one of the chordae previously marked with a stay suture (Fig 1). If there was diffuse anterior leaflet prolapse with no normal chordae, the distance from the papillary muscle head to the annulus was measured. The caliper was then locked at the chosen length and ePTFE chordae were constructed. A1 and the lateral half of A2 can be supported by chordae affixed to the anterolateral papillary muscle. A3 and the medial half of A2 can be supported by chordae attached to the posteromedial papillary muscle. In general, neo-chordae should not cross the mid-portion of the valve; therefore, in cases of diffuse anterior prolapse it may be necessary to create two sets of chordae, one set attached to each papillary muscle.
Chordal Construction
A small pledget was affixed to a CV-5 ePTFE suture and the suture was looped around the locked caliper (Fig 2). Eight knots were tied in the suture. Then each needle was passed back through the pledget (away from the surgeon) and then passed forward through the pledget (toward the surgeon); this maneuver buried the knot, preserving chordal length (Fig 3). A single chordal loop can be used to support approximately 5 to 10 mm of the free edge of the anterior leaflet. If more than one chord was necessary, one of the needles was passed back through the pledget (away from the surgeon), looped around the caliper, and then brought forward through the pledget (toward the surgeon). The knot was buried as before (Fig 4). It is unusual to require more than four chordal loops.
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Fig 2. A pledgetted CV5 e-polytetrafluoroethylene (ePTFE) suture is looped around the caliper creating a loop of appropriate length.
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Fig 3. The suture is tied and then each needle is passed back through the pledget (away from the surgeon) and then reversed and taken through the pledget toward the surgeon, burying the knot.
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Chordal Fixation
When all chordal loops are constructed, each needle was passed through the head of the papillary muscle (Fig 5). It was advantageous to pass the needles with a backhanded technique so that the chords arise from the portion of the papillary muscle that faces the surgeon. Then each needle was passed through a second pledget and the suture was tied. Care was taken not to entrap normal chordae as the ePTFE was tied.
Each ePTFE loop was affixed to the free edge of the anterior leaflet with a figure-of-eight suture of CV-5 ePTFE (Fig 6). This figure-of-eight suture should span no more than 5 mm to prevent buckling of the free edge of the anterior leaflet. If several ePTFE loops were placed, they were spaced at 5 to 10 mm intervals.
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Fig 6. Each pre-measured chord is affixed to a segment of the free edge of the anterior leaflet with a figure-of-eight suture that spans no more than 5 mm. The chordae are spaced at 5 to 10 mm intervals.
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Results
From March 2005 to February 2007, pre-measured ePTFE loops were used to treat anterior leaflet prolapse in 50 patients with moderately severe (3+) or severe (4+) mitral regurgitation. Thirty-one patients had isolated anterior leaflet prolapse, and 19 had bi-leaflet prolapse. Mean chordal length was 23 ± 3 mm, and lengths ranged from 16 to 29 mm. In 7 patients with extensive anterior leaflet prolapse, two sets of chordae of different lengths were required, one set attached to each papillary muscle. In patients with bi-leaflet prolapse, techniques used for posterior leaflet repair included sliding repair (10 patients), quadrangular resection (5 patients), and creation of neo-chordae (4 patients). All patients received a prosthetic annuloplasty band or ring. Immediately post-bypass, 47 patients had mitral regurgitation that was graded as trace to 0, and 3 patients had 1+ mitral regurgitation. Pre-discharge transthoracic echocardiograms demonstrated similar results. In follow-up ranging from 1 to 22 months, 1 patient required reoperation at 4 months for hemolysis associated with 3+ mitral regurgitation; the mechanism of recurrent mitral regurgitation was unclear, as the repair was intact at reoperation.
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Comment
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A variety of techniques are available to correct anterior leaflet prolapse. Although the creation of artificial chordae was described more than 2 decades ago, it has recently increased in popularity. The innovation by Von Oppell and Mohr [1] and the recent development of a commercially available caliper to facilitate the use of pre-measured chordae (Estech, San Ramon, CA) considerably simplifies the procedure. As with Von Oppell and Mohr [1], we find this technique to be both reliable and reproducible. We have used this procedure primarily for treatment of anterior leaflet prolapse; however, it may also be used in cases of posterior leaflet prolapse, particularly in instances when posterior leaflet prolapse is extensive or standard repair techniques are not applicable (areas of restricted and matted chordae adjacent to sites of prolapse). For correction of anterior leaflet prolapse, the most common length is 23 mm, and this should guide the surgeon as he or she applies this technique. In addition, it is important to recognize that diffuse prolapse of the anterior leaflet often requires 2 sets of chordae and that these may be of different lengths. This procedure requires visualization of the papillary muscles; if exposure of the papillary muscles is poor, we use alternate techniques like chordal transfer or, occasionally, an edge-to-edge repair. Long-term results with other techniques for creation of ePTFE chordae are excellent [2–4], and we expect that similar success will be achieved with this procedure.
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Acknowledgments
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We gratefully acknowledge Dr Mohr who described this technique and taught it to one of us (AMG).
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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]
- David TE. Artificial chordae Sem Thorac Cardiovasc Surg 2004;16:161-168.[Medline]
- Adams DH, Kadner A, Chen RH. Artificial mitral valve chordae replacement made simple Ann Thorac Surg 2001;71:1377-1379.[Abstract/Free Full Text]
- Lawrie GM, Earle EA, Earle NR. Feasibility and intermediate term outcome of repair of prolapsing anterior mitral leaflets with artificial chordal replacement in 152 patients Ann Thorac Surg 2006;81:849-856.[Abstract/Free Full Text]
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Abstract
Introduction
