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

Ann Thorac Surg 2001;72:541
© 2001 The Society of Thoracic Surgeons

Invited commentary

^a Harvard Medical School, Massachusetts General Hospital, 55 Fruit St—BUL 119, Boston, MA 02114-2696, USA

e-mail: vlahakes.gus{at}mgh.harvard.edu

Providing patients the benefits of mitral valve repair demands surgical ingenuity. Achieving durable reconstruction for anterior leaflet prolapse has been especially challenging. Recent studies have suggested that chordal transfer, using structures readily at hand, may be optimal for such repair. Timek and associates have demonstrated that in the normal heart, cutting the major second order chordae required for such repair does not adversely affect mitral valve or ventricular functions. This acute study, using elegant physiologic techniques and three-dimensional reconstruction in the normal heart, apparently lays to rest a concern in the isolated heart study of Obadia and colleagues [1] who disconnected all second order chordae. Chronically overloaded or myopathic ventricles, however, remain to be studied.

The results of Timek and associates support other potential applications of chordal disconnection. For example Messas and coworkers [2] have recently shown that in the presence of ischemic ventricular shape change with tethering of the subvalvular apparatus, intact second order chordae can create a bend or "knee" in the anterior leaflet, decreasing the area of leaflet coaptation. Cutting the major second order chordae in that setting can increase leaflet coaptation area and decrease regurgitation.

Thus, the findings of Timek and colleagues showing the safety of sacrificing secondary chordae lend support to this approach in the armamentarium of reconstructive techniques. Further research interest can focus on the question of how second order chordal cutting affects the stress applied to the primary chordae, and its consequences on long-term competence and repair durability. This important question remains to be resolved in chronic experimental and clinical follow-up studies.

References

1. Obadia J.F., Casali C., Chassignolle J.F., Janier M. Mitral subvalvular apparatus: different functions of primary and secondary chordae. Circulation 1997;96:3124-3128.[Abstract/Free Full Text]
2. Messas E, Guerrero JL, Handschumacher MD, et al. Chordal cutting: a new therapeutic approach for ischemic mitral regurgitation. Circulation 2001; in press.

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