Ann Thorac Surg 2008;85:2024-2025. doi:10.1016/j.athoracsur.2008.01.066
© 2008 The Society of Thoracic Surgeons
Original Articles: Adult Cardiac
Invited Commentary
Kenton Zehr, MD
Heart, Lung, and Esophageal Surgery Institute, University of Pittsburgh Medical Center, UPMC/Presbyterian University Hospital, 200 Lothrop St, Ste C-700, Pittsburgh, PA 15213
(Email: zehrkj{at}upmc.edu).
Fattouch and colleagues [1] present a solution to progressive aortic valve cusp prolapse after free margin adjustment: Addition of expanded polytetrafluoroethylene (ePTFE) artificial chordae tendineae from the node of Arantius to the sinotubular junction. The article is important, because first, it represents an elegant adaptation to a new anatomy of a proven surgical technique, and second, it assigns value to making final valvular repair adjustments under physiologic conditions on a beating heart.
Adaptation of proven techniques to other problems is one of the hallmarks of surgical creativity through which cardiac surgery has advanced. Examples are the adaptation of the conventional Ross aortic operation to the Ross mitral operation [2], the use of artificial chordae tendineae for tricuspid and mitral valve repair in children [3], and transapical aortic valve replacement instead of the percutaneous approach [4]. Carpentier techniques heralded the era of successful mitral valve repair, the success and durability of which continued to increase through a series of simplifications and modifications. Because transferring or shortening adjacent chordae, or both, or using diseased ones proved technically difficult and yielded poor results [5], ePTFE artificial chordae were introduced, which resulted in markedly improved durability for anterior as well as posterior leaflet repairs [6]. As failure rates for both anterior and posterior leaflet repairs, even in myxomatous valves, dropped logarithmically over 3 decades [7], the American Heart Association adopted guidelines promoting repair in asymptomatic patients with severe mitral valve regurgitation.
Progressive prolapse and failure of tricuspid aortic valves after valve-sparing aortic root reconstruction [8] and single cusp repair [9] have been more difficult to address. Fattouch and colleagues' article nicely details successful suspension of 1 or more aortic valve cusps by ePTFE artificial chordae tendineae in 26 patients without operative failure and with excellent results at 14 ± 8 months. The theory is sound, because ePTFE chordae have held up well in the mitral position under systolic pressures and is now open to validation by other centers.
Another important novelty introduced by the authors is the adjustment of the repair under physiologic conditions. Given the occasional inadequacy of merely filling the nonbeating left ventricle with saline to test for mitral valve competency or of running saline over repaired aortic valve cusps, attempts have been made either to create normal physiology while still on pump or to perform the repair completely off pump on a fully functional beating heart. In our hands, artificial mitral chordae have been reproducibly placed by using a transapical approach with the flail leaflet tied in the proper position to eliminate regurgitation (unpublished data). Fattouch and colleagues have successfully adjusted the free margins of the cusps and the height of the coaptation of the aortic valve on a fully functional beating heart. I applaud the ingenuity of the authors.
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References
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- Fattouch K, Sampognaro R, Bianco G, et al. Implantation of Gore-Tex chordae on aortic valve leaflet to treat prolapse using "the chordae technique": surgical aspects and clinical results Ann Thorac Surg 2008;85:2019-2025.[Abstract/Free Full Text]
- Kabbani S, Jamil H, Nabhani F, et al. Analysis of 92 mitral pulmonary autograft replacement (Ross II) operations J Thorac Cardiovasc Surg 2007;134:902-908.[Abstract/Free Full Text]
- Boon R, Hazekamp M, Hoohenkerk G, et al. Artificial chordae for pediatric mitral and tricuspid valve repair Eur J Cardiothorac Surg 2007;32:143-148.[Abstract/Free Full Text]
- Walther T, Simon P, Dewey T, et al. Transapical minimally invasive aortic valve implantation: multicenter experience Circulation 2007;116(11 suppl):I240-I245.[Medline]
- Phillips MR, Daly RC, Schaff HV, Dearani JA, Mullany CJ, Orszulak TA. Repair of anterior leaflet mitral valve prolapse: chordal replacement versus chordal shortening Ann Thorac Surg 2000;69:25-29.[Abstract/Free Full Text]
- Nigro JJ, Schwartz DS, Bart RD, et al. Neochordal repair of the posteriormitral leaflet J Thorac Cardiovasc Surg 2004;127:440-447.[Abstract/Free Full Text]
- Suri RM, Schaff HV, Dearani JA, et al. Survival advantage and improved durability of mitral repairfor leaflet prolapse subsets in the current era Ann Thorac Surg 2006;82:819-826.[Abstract/Free Full Text]
- Zehr KJ, Orszulak TA, Mullany CJ, et al. Surgery for aneurysms of the aortic root: a 30-year experience Circulation 2004;110:1364-1371.[Abstract/Free Full Text]
- Minakata K, Schaff HV, Zehr KJ, et al. Is repair of aortic valve regurgitation a safe alternative to valve replacement? J Thorac Cardiovasc Surg 2004;127:645-653.[Abstract/Free Full Text]
Related Article
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Implantation of Gore-Tex Chordae on Aortic Valve Leaflet to Treat Prolapse Using "The Chordae Technique": Surgical Aspects and Clinical Results
- Khalil Fattouch, Roberta Sampognaro, Giuseppe Bianco, Emiliano Navarra, Marco Moscarelli, Giuseppe Speziale, and Giovanni Ruvolo
Ann. Thorac. Surg. 2008 85: 2019-2024.
[Abstract]
[Full Text]
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