Ann Thorac Surg 2009;87:326-328. doi:10.1016/j.athoracsur.2008.05.033
© 2009 The Society of Thoracic Surgeons
How To Do It
Intracardiac Calipers for Artificial Chordae Replacement in Mitral Valve Repair
Atsuo Doi, MD*,
Hiroshi Iida, MD, PhD,
Toru Sunazawa, MD
Department of Cardiovascular Surgery, Narita Red Cross Hospital, Narita, Chiba, Japan
Accepted for publication May 13, 2008.
* Address correspondence to Dr Doi, Department of Cardiovascular Surgery, Narita Red Cross Hospital, 90-1, Iidacho, Narita, Chiba, 286-8523, Japan (Email: atsuo-doi{at}umin.net).
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Abstract
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Length adjustment of artificial chordae is crucial in the outcome of anterior mitral valve repair. Herein, a simple and reproducible method of artificial chordal replacement using polytetrafluoroethylene suture is described. With this technique, the length of the neo-chordae is easily decided and the knot can be tied surely without change in the length using only one instrument.
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Introduction
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A vital aspect in repairing mitral valve regurgitation due to anterior leaflet prolapse using expanded polytetrafluoroethylene (ePTFE) sutures is achieving proper length of the neo-chordae. We believe that making the height of the anterior leaflet the same as the posterior leaflet is the most important factor in mitral valve repair. This can be achieved by creating the neo-chordae the same length as the opposing chordae of the normal posterior leaflet as previously reported [1]. To do this we have developed a caliper that can be inserted into the left ventricle to measure the length of the chordae and at the same time can be held still while tying the ePTFE suture. This caliper can be created by simply filing off the outside jaws and removing excess parts of a commercially available vernier caliper and rounding off the edges. Therefore, it is inexpensive and easy to reproduce.
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Technique
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Length of the chordae of the posterior leaflet opposing the prolapsed portion of the anterior leaflet is first measured by transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) prior to the operation. This length is the distance between the head of the papillary muscle and the free edge of the posterior leaflet (Fig 1). The mitral valve is approached through a right-sided left atrial incision. All valve components are carefully inspected, and saline is injected into the left ventricular cavity to assess the regurgitation. Length of the opposing chordae of the posterior leaflet is measured directly using a caliper, which we have developed (Fig 2). If necessary, resection of the prolapsing segment of the anterior leaflet is performed initially. Double-armed mattress sutures with CV-5 Gore-Tex (W. L. Gore & Assoc, Flagstaff, AZ) are placed at the fibrous tip of the papillary muscle using PTFE felt (Bard Peripheral Vascular Inc, Tempe, AZ) on both sides and tied down firmly. Duran ring annuloplasty was performed in all cases; thereafter, the ePTFE suture is placed through the anterior leaflet. The needles are passed through the rough zone of the prolapsing portion from the atrial to the ventricular side, and then again through the free margin of the leaflet from the ventricular to the atrial side (Fig 3). The caliper that is fixed at the length of the opposing chordae is inserted inside the loop created by the ePTFE suture. The suture is easily and tightly tied at the exact length of the opposing chordae, and the anterior leaflet is fixed at the height of the posterior leaflet (Figs 4 and 5).
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Fig 1. Preoperative transesophageal echocardiogram. The distance between the head of the papillary muscle and the free edge of the posterior leaflet is being measured.
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Fig 3. The artificial chordae is passed through the rough zone of the prolapsing portion and then the free margin of the leaflet.
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Fig 4. Illustration of the technique used when tying the artificial chordae. The caliper is inserted in the loop created by the suture and holds at the intended length.
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Fig 5. The expanded polytetrafluoroethylene suture is being tied with the assistant holding the caliper inside the loop.
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We have applied this method in 2 patients so far, both with no regurgitation seen in the postoperative transesophageal echocardiogram. With further modification of the caliper, such as downsizing it to enable the insertion easier, the indication for this method should expand even more.
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Comment
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There are two major problems that are usually experienced when using ePTFE sutures for mitral valve repair. One is deciding the length of the neochordae, and the other is tying the knot at the intended length. With our method, both problems can be solved.
We believe making the opposing leaflets coapt at the same height is essential in mitral valve repair. In the present method, we first determine the length using TEE, and then confirm it using our caliper. Thus, the length of the neo-chordae can be made exactly the same length as the opposing chordae. Although there have been reports where the length of the neochordae is decided by the measurement achieved with TEE alone [1, 2], depiction of the normal chordae by TEE can sometimes be difficult. Therefore, we believe that direct confirmation is important. This can be easily done using our caliper. Kasegawa and colleagues [3] have described a method using small tourniquets, but we find this method complicated. Application of a caliper has been previously reported when using a pre-measured artificial chordae [4, 5]. In the present method, there is no need for extra stitches to affix the ePTFE loops.
The ePTFE sutures are difficult to tie because of their slippery nature. They tend to slip and slide when being tied down, making the neo-chordae shorter than the intended length. If the ePTFE sutures are tied by only observing the leaflet height, the position of the papillary muscle can rise unnoticed, resulting in a shortened chordae. Therefore, putting temporary edge-to-edge sutures or performing intermittent saline test seems insufficient [6, 7]. There have been reports where the length of the neo-chordae is adjusted by making multiple knots [1, 8]. In the present method, both problems can be solved using only one instrument.
The previously mentioned methods have achieved good results. However, we believe that our method has advantages, especially in cases in which the opposing posterior leaflet is normal. Our method is easy to perform and reproducible, and the short-term results have been satisfactory. It may be a useful addition to the repertoire of solutions for surgeons.
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References
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- Mandegar MH, Yousefnia MA, Roshanali F. Preoperative determination of artificial chordae length Ann Thorac Surg 2007;84:680-682.[Abstract/Free Full Text]
- Scorsin M, Al-Attar N, Lessana A. A novel technique of utilizing artificial chordae for repair of mitral valve prolapsed J Thorac Cardiovasc Surg 2007;134:1072-1073.[Free Full Text]
- Kasegawa H, Kamata S, Hirata S, Kobayashi N, Mannouji E, Ida T, Kawase M. Simple method for determining proper length of artificial chordae in mitral valve repair Ann Thorac Surg 1994;57:237-239.[Abstract/Free Full Text]
- Gillinov AM, Banbury MK. Pre-measured artificial chordae for mitral valve repair Ann Thorac Surg 2007;84:2127-2129.[Abstract/Free Full Text]
- Tam R, Joshi P, Konstantinov IE. A simple method of preparing artificial chordae for mitral valve repair J Thorac Cardiovasc Surg 2006;132:1486-1487.[Free Full Text]
- Cimen S, Ketenci B, Ozay B, Demirtas M. Neo-chordae length adjustment in mitral valve repair Eur J Cardiothrac Surg 2006;29:843-844.
- Adams DH, Kadner A, Chen RH. Artificial mitral valve chordae replacement made simple Ann Thorac Surg 2001;71:1377-1379.[Abstract/Free Full Text]
- Shudo Y, Taniguchi K, Takahashi T, Matsue H. Simple and easy method for chordal reconstruction during mitral valve repair Ann Thorac Surg 2006;82:348-349.[Abstract/Free Full Text]
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Abstract
Introduction
