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Correspondence

Adjusting the Length of Goretex Artificial Chordae

Department of Cardiovascular Surgery, University Hospital of Liège, CHU Liège, B 35, Domaine Universitaire du Sart-Tilman, Liège, 4000 Belgium

(Email: mradermecker{at}chu.ulg.ac.be).

To the Editor:

I read with interest the article from Doi and colleagues [1] regarding the use of an intracardiac caliper to adjust the length of expanded polytetrafluoroethylene (ePTFE) sutures used as artificial neochordae to correct mitral leaflet prolapse. Since the seminal publication of Zussa and colleagues [2], the ePTFE Goretex CV-4 or CV-5 sutures (W. L. Gore & Assoc, Flagstaff, AZ) have evolved as a cornerstone tool for the correction of mitral or tricuspid valve prolapse [3]. In the long term, these neochordae become encased with a fibrous neointimal sheet and retain both strength and flexibility.

As rightly emphasized by Doi and colleagues [1], this versatile technique implies: (1) the precise adjustment of the neochordae length, and (2) that this adequate length is not reduced during knot tying because of the slippery nature of the ePTFE, or by inadvertent traction on the head of the corresponding papillary muscle.

Their interesting technical suggestion undoubtedly tackles these two pitfalls. However, the proposed instrument may be somewhat cumbersome in the case of difficult mitral valve exposure. We also interpret this new technical development as another attempt to make a conceptually evident repair technique easy and reliable. Among the other technical proposals, the authors mention the temporarily edge-to-edge stitch and the filling of the ventricle with saline for chordal length adjustment, the small tourniquet technique of Kasewaga [4] and the use of premeasured artificial chordae.

This brief review omits a valuable technique that has been developed and published by our Belgian colleagues in Brussels [5]. Because of its rationale, simplicity, and efficacy, this technique should be re-emphasized. It relies on the geometric relationship between the valve free edge (FrE), the annulus (A) and the tip of the papillary muscle (T) especially in degenerative disease. In first approximation, the length of the neochordae should be similar to the distance between the tip of the papillary muscle and the annulus (Fig 1). After placing the neochordae in the fibrous part of the corresponding papillary muscle, the two arms of the neochordae are passed twice through the free edges in a loose, locking fashion. The next step is to bring the free margin without pulling on the papillary muscle toward the annulus, and then locking the suture tightly (at the TA length). The sutures are then passed toward the ventricular aspect of the leaftlet and definitively tied [5].

View larger version (14K): [in this window] [in a new window]   Fig 1. Schematic representation of the mitral valve leaflets and subvalvular apparatus.

	References

Top References

 

1. Doi A, Iida H, Sunazawa T. Intracardiac calipers for artificial chordae replacement in mitral valve repair Ann Thorac Surg 2009;87:326-328.[Abstract/Free Full Text]
2. Zussa C, Frater RW, Polesel E, Galloni M, Valfré C. Artificial mitral valve chordae: experimental and clinical experience Ann Thorac Surg 1990;50:367-373.[Abstract/Free Full Text]
3. David TE, Bos J, Rakowski H. Mitral valve repair by replacement of chordae tendinae with polytetrafluoroethylene sutures J Thorac Cardiovasc Surg 1991;101:495-501.[Abstract]
4. Kasegawa H, Kamata S, Hirata S, Kabayashi N, Mannouji E, Kawase M. Simple method for determining proper length of artificial chordae in mitral valve repair Ann Thorac Surg 1994;57:237-238.[Abstract/Free Full Text]
5. El Khoury G, Noirhomme P, Verhelst R, Rubay J, Dion R. Surgical repair of the prolapsing anterior leaflet in degenerative mitral valve disease J Heart Valve Dis 2000;9:75-81.[Medline]

This article has been cited by other articles:

				A. Doi, H. Iida, and T. Sunazawa Reply Ann. Thorac. Surg., January 1, 2010; 89(1): 345 - 345. [Full Text] [PDF]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Marc A. Radermecker Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Radermecker, M. A. Search for Related Content PubMed PubMed Citation Articles by Radermecker, M. A. Related Collections Valve disease Related Article