Mitral valve replacement for extensive calcification: half and half technique

A 50-year-old woman who had been undergoing hemodialysis for 18 years underwent mitral valve replacement because of mitral valve stenosis. Her mitral valve leaflet and annulus were highly calcified, and it was impossible to remove the posterior leaflet from the ventricular wall. At the time of surgery, noneverted horizontal mattress sutures were placed from the left ventricle to the left atrium on the anterior half of the mitral annulus and everted horizontal mattress sutures on the left atrial wall close to the calcified posterior annulus. A 25-mm St. Jude valve was seated successfully at a supra-annular position. The St. Jude valve is suitable for this technique because its leaflets protrude less into the left ventricle.     

Use of the anterior mitral leaflet to reinforce the posterior mitral annulus after debridement of calcium.

In mitral valve surgery, preservation of continuity between the papillary muscles, chordae, and annulus is associated with preservation of left ventricular function and reduced risk of postoperative left ventricular rupture. However, at mitral valve replacement, extensive annulus and leaflet calcification can necessitate resection of the posterior mitral leaflet. We describe a technique in which the anterior mitral leaflet and its subvalvular apparatus are used to reinforce the posterior mitral annulus after extensive debridement of calcium along the same annulus.     

The rheumatic mitral valve and repair techniques in children

The mitral valve is the most commonly affected valve in acute and chronic rheumatic heart disease in the first and second decades of life. Pure or predominant mitral regurgitation with non-significant stenosis (mitral valve area > 1.5 cm(2) on echocardiography) is the most frequently encountered valvular dysfunction in children. In our experience, based on 428 children operated between 1993 and 2011 at our institution, functional classification based on leaflet motion assessed by echocardiography and reconfirmed peroperatively revealed pure annulus dilatation (type I) in 7% of patients, anterior leaflet prolapse (type IIa) in 33%, combination of anterior leaflet pseudoprolapse with restricted motion of the posterior leaflet (type pseudoIIa/IIIp) in 34%, and restricted anterior and posterior leaflet motion (type IIIa/p) in 26%. Patients with type III were older than those with type IIa and type pseudoIIa/IIIp. Different techniques can be used to repair rheumatic mitral valve lesions: prolapse of the anterior leaflet caused by chordal elongation or rupture can be treated by chordal shortening, chordal transfer, or artificial chordal replacement; restricted motion of the anterior and/or posterior leaflet can be treated by commissurotomy, splitting of the papillary muscles, resection of the secondary, or sometimes primary posterior chordae, posterior leaflet free edge suspension, leaflet thinning, and leaflet enlargement using autologous pericardium. Because mitral annulus dilatation is present in almost all patients with mitral regurgitation, concomitant ring annuloplasty offers more stability in valve repair, improving long-term outcome. The major causes for failure of rheumatic mitral valve repair are the presence of ongoing rheumatic inflammation at the time of surgery, use of inappropriate techniques, technical failures requiring early reoperation, lack of concomitant ring annuloplasty, and progression of leaflet and chordal disease further resulting in more leaflet retraction, thickening, and deformity. Freedom from reoperation depends on mitral regurgitation functional type, the type IIa and type pseudoIIa/IIIp having a better long-term outcome than type I and type III, in our series. In conclusion, mitral valve repair should be a preferred strategy in children with rheumatic heart disease whenever feasible, providing stable actuarial survival with fewer thromboembolic complications in a pediatric population noncompliant to anticoagulation.     

Perivalvular leakage 25 years after initial mitral valve replacement with a Björk-Shiley prosthesis

An 80-year-old woman had undergone initial mitral valve replacement using a Björk-Shiley mechanical valve owing to mitral stenosis 25 years earlier. Suddenly, she had anemia and an increased lactic dehydrogenase (LDH) level. Transesophageal echography (TEE) showed perivalvular leakage. In a redo operation, two side-by-side stitches of the valve on the posterior annulus were loosened without cutting and the sewing cuff at that site was floated over the annulus, leading to the perivalvular leakage. The valve was easily removed; and round, hard, degenerative calcified tissue composed of remnant mitral valve in the suture site during the initial operation was found just under the sewing cuff. After resection of this calcified round tissue, a 25-mm bioprosthesis was put in place. Her postoperative recovery was uneventful, and 47 days after surgery she was discharged without perivalvular leakage or anemia.     

Mitral valve replacement with posterior transposition of the anterior mitral leaflet which covers and buttresses partially decalcified posterior mitral annular bed

Mitral valve replacement (MVR) in the presence of the extensive calcification of the mitral annulus is a technical challenge. The heavily calcified annulus can cause great difficulty in the insertion of a prosthetic valve and periprosthetic leakage later on. Vigorous annular decalcification may cause circumflex coronary artery injury, atrioventricular rupture and thromboembolic events. We herein describe a surgical technique for MVR in such cases while focusing on partial decalcification of the posterior mitral annulus and its reinforcement and buttressing with the transferred anterior mitral leaflet (AML). At the same time, the transferred AML supports the posterior annular region and maintains ventricular-annular continuity, thus preserving the left ventricular function.     

Mitral annular reconstruction with anterior leaflet flip-over in concomitant surgery for mitral regurgitation associated with extensive posterior annular calcification and hypertrophic obstructive cardiomyopathy

We describe a case of severely calcified posterior mitral annulus associated with grade IV mitral re-gurgitation in addition to significant hypertrophic obstructive cardiomyopathy. A 70-year-old woman underwent successfully annular reconstruction with anterior mitral leaflet flip-over and mitral valve replacement with a bileaflet mechanical prosthesis combined with left ventricular septal myectomy. This technique can serve not only to cover the debrided posterior annulus, but also to eliminate left ventricular outflow tract obstruction and to keep left ventricular function by virtue of not severing ventricular-annular continuity.     

Use of the pericardial cord as a substitute for an infected mitral prosthetic ring associated with aortic prosthetic valve endocarditis

We report the case of a 61-year-old man with prosthetic valve endocarditis after both aortic valve replacement and mitral annuloplasty. Necrotic tissue and dehiscence of the suture line in the aortic annulus were found, and the infection extended to the anterior portion of the mitral prosthetic ring. The autologous pericardial cord was used as a substitute for the infected mitral prosthetic ring, and aortic root replacement was performed with a stentless bioprosthesis. The autologous pericardial cord was useful as a substitute for an infected mitral prosthetic ring.     

Repair of Mitral Regurgitation from Myxomatous Degeneration in the Patient with a Severely Calcified Posterior Annulus

Severe posterior annular calcification poses a particular challenge to mitral valve repair. In a series of 252 mitral valve repairs for myxomatous degeneration performed between 1980 and 1993, 14 patients had a severely calcified posterior mitral valve annulus. Ages ranged from 61 to 81 years. Twelve patients were preoperative NYHA Class III or IV, and five patients required concurrent coronary artery bypass procedures. Operative techniques included complete resection of the calcified posterior annulus, resections of portions of the posterior leaflet with leaflet advancement, and placement of an annuloplasty ring. There were no operative deaths and all patients had a postoperative echocardiographic confirmation of relief from mitral regurgitation. During a mean follow-up time of 36 months (6 months to 8 years), there has been one late valve reoperation and only one late death, from thromboembolism in a patient with atrial fibrillation. These data indicate that even in the presence of severe calcification of the posterior mitral annulus, mitral valve repair for myxomatous degeneration can be performed with a low-operative risk and satisfactory long-term results.     

Mitral valve reconstruction: long-term results of triangular resection for degenerative prolapse

Objectives. Surgical treatment of a prolapsed anterior leaflet of the mitral valve is relatively difficult and controversial compared with management of a prolapsed posterior leaflet. The aim of this study was to assess the long-term results of mitral valve repair, focusing on triangular resection of the anterior leaflet. Methods. Between October 1991 and December 2006, surgical treatment for a prolapsed anterior leaflet was performed in 57 patients with degenerative mitral valve disease, including 49 patients who had anterior leaflet resection. Patients with mitral stenosis, ischemic mitral regurgitation, and congenital valvular disease were excluded. The mean age of the patients was 51.7 ± 15.9 years, and the mean follow-up period was 6.2 ± 3.8 years. Results. The overall actuarial survival rate and noreoperation rate at 10 years were 91.7% ± 4.1% and 92.3% ± 3.7%, respectively. Reoperation was performed in 2 (4%) of 49 patients who had anterior leaflet resection. All patients survived after reoperation, which involved mitral valve replacement. Postoperative echocardiographic studies showed that the mitral valve area was significantly smaller after repair in patients with anterior leaflet resection, but the area was still large enough for a functional valve. Among the 57 patients, 42 had no mitral regurgitation, whereas it was mild in 7 patients and moderate in 3 patients. Conclusion. Triangular resection of a prolapsed anterior leaflet of the mitral valve provides durable and reliable long-term results.     

Traumatic mitral insufficiency following percutaneous mitral dilation: anatomic lesions and surgical implications

Percutaneous mitral dilation is a widely accepted technique for treating pure mitral stenosis. Traumatic mitral insufficiency may occur secondary to this technique raising the problem of the feasibility of mitral valve repair. Twenty patients were operated on for traumatic mitral insufficiency following percutaneous mitral dilation. Three patients required emergency operations (within 6 h). In the other cases, surgery was carried out within the following days or weeks. Operative analysis of the mitral valves showed the following lesions: tear of the anterior leaflet (n = 4), tear of the posterior leaflet (n = 2), anterior (n = 4) or posterior (n = 9) paracommissural tear and papillary muscle rupture (n = 1). Associated chordal rupture was found in 3 patients. Septal perforation secondary to transseptal puncture was found in all cases. A septal tear of more than 10 mm was present in 4 patients. Surgery consisted of mitral valve reconstruction (n = 12) or mitral valve replacement (n = 8). Anatomic lesions following percutaneous mitral dilation may affect all the elements of the mitral valve apparatus. The possibility of repair depends more on the degree of calcification of the valve than on the extent of the leaflet tear.     

The effects of mitral annuloplasty rings on mitral valve complex 3-D geometry during acute left ventricular ischemia.

OBJECTIVE: Annuloplasty rings are used to treat ischemic mitral regurgitation (IMR), but their exact effects on 3-D geometry of the overall mitral valve complex during acute left ventricular (LV) ischemia remain unknown. METHODS: Radiopaque markers were sutured to the mitral leaflet edges, annulus, papillary muscle tips, and ventricle in three groups of sheep. One group served as control (n = 5), and the others underwent Duran (n = 6) or Physio (n = 5) ring annuloplasty. One week later, 3-D marker coordinates at end-systole were obtained before and during balloon occlusion of the circumflex artery. RESULTS: In all control animals, acute LV ischemia was associated with: (i) septal-lateral separation of the leaflet edges, which was predicted by lateral displacement of the lateral annulus during septal-lateral mitral annular dilatation; (ii) apical restriction of the posterior leaflet edge, which was predicted by displacement of the lateral annulus away from the non-ischemic anterior papillary muscle; (iii) displacement of the posterior papillary muscle, which was not predictive of either septal-lateral leaflet separation or leaflet restriction; and (iv) mitral regurgitation. In the Duran group during ischemia, the posterior leaflet edge shifted posteriorly due to posterior movement of the lateral annulus, but no IMR occurred. In the Physio group during ischemia, neither the posterior leaflet edge nor the lateral annulus changed positions, and there was no IMR. In both the Duran and Physio groups, displacement of the posterior papillary muscle did not lead to IMR. CONCLUSIONS: Either annuloplasty ring prevented the perturbations of mitral leaflet and annular--but not papillary muscle tip--3-D geometry during acute LV ischemia. By fixing the septal-lateral annular dimension and preventing lateral displacement of the lateral annulus, annuloplasty rings prevented systolic septal-lateral leaflet separation and posterior leaflet restriction, and no acute IMR occurred. The flexible ring allowed posterior displacement of the posterior leaflet edge and the lateral annulus, which was not observed with a semi-rigid ring.     

Etiology of left ventricular rupture following mitral valve replacement]

Two uncommon cases of left ventricular rupture that occurred during cardiac surgery were treated successfully. These cases may be useful in understanding the etiology of common left ventricular rupture following mitral valve replacement. One case occurred during coronary bypass surgery. The myocardium which is already abnormal seems to be weak to trauma such as bending, traction and torsion. In the other case, who underwent mitral valve replacement with preservation of the posterior leaflet with its attached chordae, the disruption was localized in the epicardial side of the left ventricular posterior wall, though direct injury by some instrument was excluded as a possibility, with a depth of half the thickness of the wall. In experiments using dogs, shape and movement of the mitral annulus were examined. The length of the annulus attached to the posterior leaflet in end-systole was shortened to 89.0 +/- 4.6% of that in late diastole. Furthermore, the annulus was distorted by the elevation of the heart. We approve of Cobbs' "untethered ventricle theory" and consider moreover as follows: In general, whether with or without preservation of the mitral loop, the mitral annulus and the left ventricular posterior wall after mitral valve replacement are severely constricted by the rigid prosthetic ring and become tense, which limits movement in both circular and longitudinal directions. Then even slight stress may cause a primary tear on the posterior wall of the left ventricle, resulting in rupture. In order to treat the rift, the prosthesis must be removed before the apex of the heart is lifted, to avoid excessive ventricular wall tension.     

Early and late results of partial plication annuloplasty for congenital mitral insufficiency

BACKGROUND: Partial plication annuloplasty is the main technique for congenital mitral insufficiency because this technique allows the mitral anulus to grow, in contrast to ring annuloplasty. However, this technique is not satisfactory for mitral insufficiency with some anomalies of the mitral valve apparatus. METHODS: Forty-one patients underwent partial plication annuloplasty for mitral regurgitation from July 1979 to December 1998. Mitral regurgitation associated with an atrioventricular defect, an atrioventricular discordance, and a univentricular heart was excluded from this study. RESULTS: There were no early or late deaths. In early results, partial plication annuloplasty was more effective for mitral regurgitation with abnormality of the posterior leaflet (n = 14) or normal leaflet motion (n = 8) than with abnormality of the anterior leaflet and its apparatus (n = 14) or absence of chordae (n = 4). The mean follow-up period was 145.8 months. During the follow-up period, 2 patients underwent mitral valve replacement, and a third patient underwent mitral valve repair with partial plication annuloplasty after the first repair. The main cause of mitral regurgitation of 2 of the 3 patients was absence of chordae. The actuarial freedom from reoperation rate was 94.9% +/- 3.6%, 91.9% +/- 4.7%, and 91.9% +/- 4.7% at 5, 10, and 15 years after the operation, respectively. CONCLUSION: Early and long-term results of partial plication annuloplasty were acceptable for congenital mitral insufficiency with any type of malformation of the mitral valve, and results were excellent with abnormality of the posterior leaflet and its apparatus or normal leaflet motion. However, late results were suboptimal for mitral regurgitation with absence of chordae. Other techniques, such as artificial chorda replacement, should be adapted in these cases.     

Restricted posterior leaflet motion after mitral ring annuloplasty

Background. The effects of ring annuloplasty on mitral leaflet motion are incompletely known. The three-dimensional dynamics of the mitral valve in vivo were examined to determine how two types of annuloplasty rings affect leaflet motion during valve closure.

Methods. Miniature radiopaque markers on the mitral leaflets, annulus, and left ventricle were implanted in three groups of sheep. One group served as control (n = 7); other sheep were randomly assigned to receive either a flexible Duran (n = 6) or a semirigid Carpentier-Edwards Physio ring (n = 6). After recovery, three-dimensional marker coordinates were computed from simultaneous (60 Hz) biplane videofluoroscopic marker images.

Results. Both types of rings immobilized the middle scallop of the posterior leaflet without affecting anterior leaflet motion. The excursion of the anterior leaflet edge from maximally open to fully closed was not different between the groups (control, 13 ± 2 mm; Duran 13 ± 1 mm; Physio ring, 14 ± 1 mm; p > 0.05), but posterior leaflet edge excursion was restricted (control, 7.4 ± 0.4 mm; 2.3 ± 0.3 mm [p < 0.001]; Physio, 2.7 ± 0.2 mm [p < 0.001]) by both rings.

Conclusions. Mitral annuloplasty with either ring type markedly reduced the mobility of the central posterior leaflet in normal ovine hearts such that valve closure became essentially a single (anterior) leaflet process with the frozen posterior leaflet serving only as a buttress for closing.     

实时三维超声在人工腱索二尖瓣成形术中的应用

目的 评价实时三维超声心动图在人工腱索植入行二尖瓣成形术中的应用价值.方法 31例二尖瓣脱垂病人,采用4-0 Goretex线为材料构建人工腱索行二尖瓣成形术,在术前、术中和术后分别行实时三维超声心动图检查.术前测量病人的正常腱索长度,通常测量二尖瓣前叶A1节段和后叶P1节段的腱索长度,以指导手术方案的制定.术中和术后采用实时三维超声检查以评价手术治疗效果.术中所有病人均同时植入人工二尖瓣成形环.结果 无手术死亡病例,体外循环(142.0±31.2)min、主动脉阻断(98.0±22.5)min.每例病人植入人工腱索1～3根,平均(2.0±1.5)根.术前三维超声测量的人工腱索的预期长度平均为(21.0±2.5)mm,术中实际植入的人工腱索的长度平均为(20.0±2.2)mm,二者比较差异无统计学意义.随访3～30个月,随访率98%.出现轻微反流15例,轻度反流1例,中度反流1例,无需再次手术治疗病例.未发现Goretex线人工腱索断裂,无后期死亡.结论 人工腱索植入二尖瓣成形术可获得良好的近、中期效果,实时三维超声可准确预测人工腱索的长度,对提高手术效果有重要帮助.     

Sustained improvement after combined anterior mitral valve leaflet retention plasty and septal myectomy in preventing systolic anterior motion in hypertrophic obstructive cardiomyopathy in children

Objective: Anatomic alterations of the mitral valve such as increased mitral leaflet area, length and laxity, and anterior displacement of the papillary muscles in hypertrophic obstructive cardiomyopathy predispose patients to residual systolic anterior motion and persistence of outflow obstruction and mitral regurgitation after septal myectomy. We investigate the long-term results of combined anterior mitral leaflet retention plasty and septal myectomy in children with hypertrophic obstructive cardiomyopathy. Methods and results: Anterior mitral leaflet retention plasty and subaortic septal myectomy were performed in 12 children (mean age 10.8 ± 1.7 years) with hypertrophic obstructive cardiomyopathy. Mean preoperative left ventricular outflow tract pressure gradient was 49 ± 11 mmHg. After careful assessment of the mobility of the anterior leaflet and subvalvular apparatus, segments of the anterior leaflet nearest the trigones were sutured to the corresponding posterior annulus with polypropylene reinforced with untreated autologous pericardial pledgets. Intraoperative valve orifice measurement based on age-related valve diameter ensures that no mitral stenosis is produced. Mean intraoperative pre- and post-septal myectomy pressure gradient was 60 ± 25 mmHg and 5 ± 6 mmHg, respectively. Post-myectomy mitral insufficiency was reduced to a regurgitant fraction of 0–10%. Mean follow-up is 11.85 ± 1.22 years. Mean left ventricular outflow tract pressure gradient was 6.2 ± 3.95 mmHg. No mortality, no repeat myectomy or repeat mitral valve repair or replacement, no mitral stenosis and no systolic anterior motion occurred. Conclusions: Long-term follow-up shows sustained absence of systolic anterior motion, attenuation of mitral regurgitation, sustained improvement in functional status, and reduction of outflow tract obstruction.     

二尖瓣前叶脱垂个性化成形67例临床分析

目的分析二尖瓣成形术矫治二尖瓣前叶脱垂的近、远期疗效,总结其临床经验。方法2002年1至2013年6月北京安贞医院心脏外科应用“缘对缘”成形、人工腱索、腱索缩短、“缘对缘”腱索转移法等各种成形击治疗二尖瓣前叶脱垂共67例,其中男41例、女26例,年龄18～71（46．34±7．68）岁,体重43～91（65．30±18．60）．术前心功能分级（NYHA）Ⅱ级5例,Ⅲ级27例,Ⅳ级35例。腱索断裂46例,腱索延长21例。二尖瓣反流面（15．36±4．53）cm^2,术前左心室射血分数29％～71％。所有患者出院前、术后6个月及以后每1～2年再次行超声心动图检查,以观察二尖瓣成形术矫治二尖瓣前叶脱垂的近、远期疗效。结果 围术期无死亡。除1例患者术后第3d出现瓣膜穿孔,1例术后6个月因成形环撕脱导致血红蛋白尿,再次行心瓣膜成形术外,其余患者均无需二次手术。随访67例,随访率100％,随访时间2～138（65．6±17.3）个月。随访期间无死亡,术后心功能分级（NYHA）全部恢复至Ⅰ级。术后复查超声心动图二尖瓣瓣口面积2_3～4：8（3．63±0．79）cm^2,均无明显反流,反移积（O．574±0．37）cm^2,术后左心房内径[（38．23±11．56）mm vs．（49．26±10．36）mm,P〈0．05]、左心室舒张期末p[（43．35±13．74）mm vs．（64．29±12．54）mm,P〈0．05]较术前明显缩小。结论几乎所有二尖瓣前叶脱垂患{可以通过个性化二尖瓣成形手术治疗获得良好的手术效果。     

Surgical repair of mitral valve prolapse through a minimal right vertical infraaxillary thoracotomy

Abstract Background: Minimally invasive mitral valve surgery has been proven a safe and cosmetic alternative to the conventional median sternotomy approach. The aim of this study is to retrospectively evaluate the clinical outcome of mitral valve repair for leaflet prolapse through a minimal right vertical infraaxillary thoracotomy (RVIAT). Methods: From January 2003 to December 2011, 68 patients with mitral regurgitation (MR) due to leaflet prolapse underwent mitral valve repair through a RVIAT approach. There were 37 males and 31 females. The mean age of the patients was 37.8 ± 10.5 years. Of the 68 patients, 45 had posterior leaflet prolapse and 23 had anterior leaflet prolapse. Results: The mean incision length was 7.3 ± 1.8 cm (range 5.5 to 10.0 cm). Mitral valve repair technique included quadrangular resection with or without sliding repair (40 cases), edge to edge technique (six cases), artificial chordae (18 cases), chordal transfer (four cases), and ring annuloplasty was performed in all 68 patients. There was no severe morbidity and operative mortality. Echocardiography after operation demonstrated absence or trivial mitral regurgitation in 52 patients and mild regurgitation in 16 patients. During the 3 months ～8 years' follow-up period, one patient (1.5%) underwent mitral valve replacement through the median sternotomy due to recurrent severe MR. Other patients were in good condition. Conclusion: Surgical repair of mitral valve prolapse can be successfully performed through the RVIAT approach achieving excellent cosmetic and clinical results. (J Card Surg 2012;27:533-537).     

Combined valve surgery in end-stage renal disease patient with porcelain aorta and mitral annulus calcification

A 66-year-old woman, who had been receiving regular hemodialysis for 11 years, was referred to our hospital because of heart failure due to combined valve disease complicated by porcelain aorta and mitral annulus calcification. We performed ascending aortic replacement under hypothermic arrest, and double valve replacement and tricuspid valve annuloplasty during rewarming. It was noted that the annulus of P3 of mitral valve had been replaced with atherosclerotic plaque containing calcification. We did not perform débridement. We placed non-everted horizontal mattress sutures from the left ventricle to the atrium on the anterior annulus and P1 to P2 annulus, and everted horizontal mattress sutures on the left atrial wall close to the calcified P3 annulus. Then, we successfully replaced the mitral valve with a 23-mm St. Jude Medical valve in a supra-annular position. The patient was discharged from the hospital 44 days after the operation.     

Artificial chordae

Expanded polytetrafluoroethylene sutures have been used for replacement of chordae tendineae since 1985. They have been used for correction of prolapse of mitral and tricuspid valve leaflets as well as for resuspension of the papillary muscles during mitral valve replacement when the native chordae cannot be preserved to maintain continuity between the mitral annulus and papillary muscles. The sutures used were 5CV Gore-Tex for replacement of the chordae tendineae of the anterior leaflet and 6CV for the posterior leaflet and commissural areas of the mitral valve. Initially one suture was used to create two artificial chordae, but as experience increased, the technique was modified and multiple pairs of artificial chordae were created with a single suture by passing successively through the fibrous portions of the a papillary muscle and the free margin of the prolapsing segment of leaflet, and tying the tends together on the papillary muscle head. This technique creates artificial chordae that are interdependent and their lengths are self-adjusting when pressure is exerted on the leaflets. From 1985 to 1998, 288 patients had artificial chordae used during mitral valve repair for degenerative disease of the mitral valve. Prolapse of both leaflets was present in 51% of patients, isolated prolapse of the anterior leaflet in 28%, and posterior leaflet in 21%. The mean follow-up was 4.8 +/- 3.0 years and was complete. At 10 years, the freedom from mitral regurgitation >2+ was 88 +/- 6% and the freedom from reoperation was 92 +/- 2%. Failures of repair were unrelated to the artificial chordae. Gore-Tex sutures are an excellent material to replace chordae tendineae, appear to be free of adverse effects, and have become a valuable adjunct to the surgical armamentarium to treat mitral and tricuspid valve disease.