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.     

Anterior mitral leaflet prolapse as a primary cause of pure rheumatic mitral insufficiency

BACKGROUND: This study was designed to revise the mechanisms and repair techniques of anterior mitral leaflet prolapse observed during the correction of pure rheumatic mitral regurgitation in children. METHODS: From March 1993 to May 1998, 36 children suffering from pure rheumatic mitral regurgitation due to anterior leaflet prolapse underwent mitral valve repair. The mean age was 12.5 years (range, 6 to 16 years). Anterior leaflet prolapse was due to chordal elongation in 25 patients (group A), chordal rupture in 6 patients (group B), and retraction of anterior secondary chordae tendineae, creating a V-shaped deformity in the middle of the anterior leaflet, thus moving the free edge of the anterior leaflet away from the coaptation plane, in 5 patients (group C). Chordal shortening, transposition, and resection of anterior secondary chordae tendineae were used to correct anterior leaflet prolapse according to the predominantly responsible mechanism. RESULTS: All patients were available for clinical follow-up, which ranged from 6 months to 5 years (mean follow-up, 3 years). Echocardiographic studies were obtained until the 3rd postoperative month, and all patients showed significant improvement in their left ventricular and atrial dimensions. There was one late death related to endocarditis. Two patients in group C who had mitral valve repair underwent mitral valve replacement on the 19th and 24th postoperative months, respectively, because of failure of mitral valve repair. CONCLUSIONS: Mitral valve repair for pure mitral regurgitation due to rheumatic anterior leaflet prolapse can be performed safely for all types of mechanisms. Although the techniques we used provide stable short-term results in each of these groups, midterm results are better in groups A and B, where tissue thickening is less important, recurrences of rheumatic carditis are lower, and the interval between the first rheumatic attack and the surgical procedure is shorter than in group C.     

改良腱索转移法治疗二尖瓣前叶脱垂(附16例临床分析)

目的 介绍一种操作简单、效果可靠的矫治二尖瓣前叶脱垂的手术方法.方法 2002年1月至2008年5月,应用"缘对缘"技术基础上的腱索转移法治疗二尖瓣前叶脱垂共16例,其中腱索断裂12例,腱索延长4例.超声心动图均显示二尖瓣前叶脱垂致重度关闭不全,平均反流面积(14.76±3.28)cm2,左心室射血分数33%～69%.按照NYNA分级,术前心功能Ⅲ级5例,Ⅳ级11例.手术首先行脱垂部位前瓣与相应部位后瓣的"缘对缘"缝合,矩形切下缝合处的后瓣,连同相应的腱索、乳头肌,转移至前瓣.再行后瓣成形,完成瓣膜成形手术.所有病人出院前和随访时再次行超声心动图检查.结果 手术无死亡,除1例因为术后第3天出现二尖瓣前叶穿孔再次行二尖瓣置换手术外,其余15例手术病人均顺利康复出院.术后远期随访无死亡,心功能全部恢复至Ⅰ级.复查超声心动图二尖瓣瓣口面积3.3-4.8 cm2,平均(3.78±0.52)cm2,均无明显反流,反流面积(0.45±0.22)cm2,左房、左室明显缩小[(左房径:术前(48.26±11.12),mm,术后(37.57±9.56)mm,P=0.028;左窜舒张末径术前(61.43±8.24)mm,术后(42.35±10.79)mm,P=O.008].结论 "缘对缘"技术基础上的腱索转移法治疗二尖瓣前叶脱垂,操作简单,可以取得良好的成形效果.     

Replacement of Mitral Valve Posterior Chordae Tendineae with Expanded Polytetrafluoroethylene Suture: A Finite Element Study

A bstract Background and Aims : Expanded polytetrafluoroethylene (ePTFE) suture has been used clinically for replacement of ruptured mitral valve chordae tendineae. The purpose of this study was to assess mitral valve function after posterior chordal replacement with ePTFE suture. Methods : A three-dimensional finite element computer model of the mitral valve was used, which incorporated geometry, regional tissue thickness, collagen fiber orientation, and anisotropic material properties for the leaflets, interface, and chordae tendineae. To simulate chordal rupture, four marginal and four basal chordae were removed from the posterior leaflet. Chordal replacement was simulated using two elements with the physical and material properties of 2–0 ePTFE suture. Systolic loading pressures were applied. Results : The chordal rupture model demonstrated posterior leaflet prolapse, abnormal stress concentrations, potential regurgitation, and elevated chordal stress. Conversely, the chordal replacement model corrected the prolapse and returned chordal stress to normal levels. However, stress concentrations were shown at suture attachment points. Conclusions : This integrated mitral valve finite element model provides a tool to investigate the performance of the valve system. In this study, we have shown that 2–0 ePTFE suture replacement of ruptured posterior chordae tendineae returns the valve to a near normal state, in terms of leaflet stress and coaptation, and chordal stresses.     

An effective technique to correct anterior mitral leaflet prolapse

Up to one-third of the patients with degenerative mitral valve disease and severe mitral regurgitation have anterior mitral valve prolapse due to chordal rupture or elongation. Surgical treatment of such a condition is often technically demanding and not infrequently associated with suboptimal results. Techniques used to treat anterior leaflet prolapse include chordal transfer, chordal shortening, artificial chordae, and anterior leaflet resection or plication. Each of these strategies has potential shortcomings, and there is considerable controversy concerning the durability of anterior leaflet prolapse repairs using these techniques. The "edge-to-edge" technique, a simple and effective method of correcting anterior mitral leaflet prolapse is described.     

Imbalanced chordal force distribution causes acute ischemic mitral regurgitation: mechanistic insights from chordae tendineae force measurements in pigs

BACKGROUND: Ischemic mitral regurgitation is caused by an imbalance of the entire mitral-ventricular complex. This interaction is mediated through the chordae tendineae force distribution, which may perturb several elements of the mitral valve apparatus. Our objective was to investigate the association between the mitral valvular 3-dimensional geometric perturbations and chordae tendineae force redistribution in a porcine model of acute ischemic mitral regurgitation. METHODS: In 9 pigs, acute ischemic mitral regurgitation was induced by repeated microembolization of the left circumflex coronary artery. Mitral leaflet coaptation geometry was determined by 2-dimensional echocardiography and reconstructed 3-dimensionally. Leading edge chordal forces were measured by dedicated miniature force transducers at control and during ischemic mitral regurgitation. RESULTS: During acute ischemic mitral regurgitation, there was a decreased tension of the primary chorda from the ischemic posterior left ventricular wall to the anterior leaflet (0.295 +/- 0.063 N vs 0.336 +/- 0.071 N [control]; P < .05). The tension of the chorda from the nonischemic anterior left ventricular wall to the anterior leaflet increased (0.375 +/- 0.066 N vs 0.333 +/- 0.071 N [control]; P < .05). In accordance, relative leaflet prolapse was observed at the ischemic commissural side, whereas there was an increase in the leaflet surface area at the nonischemic commissural side, indicating localized leaflet tethering. CONCLUSIONS: Acute ischemic mitral regurgitation due to posterior left ventricular wall ischemia was associated with focal chordal and leaflet tethering at the nonischemic commissural portion of the mitral valve and a paradoxical decrease of the chordal forces and relative prolapse at the ischemic site of the anterior mitral valve leaflet.     

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).     

Mitral valve repair for anterior leaflet prolapse: surgical techniques review and 16-year follow-up results

Abstract   Objective: Mitral valve repair is now the surgical treatment of choice for mitral regurgitation. However, the repair of anterior leaflet prolapse due to chordal rupture or elongation remains a technically challenging procedure. Here, we review our experience and present the long-term results of mitral valve repair for mitral regurgitation due to anterior leaflet prolapse. Methods: Between January 1988 and August 2006, 210 patients with mitral regurgitation underwent mitral valve reconstruction. We performed mitral valve repair in 49 patients with mitral regurgitation due to anterior leaflet prolapse. The preoperative degree of mitral regurgitation was moderate to severe in all patients. There were 36 patients (73.5%) with degenerative, eight (16.3%) with infective endocarditis, and five (10.2%) with rheumatic. Reconstructive techniques included chordal replacement in 13 patients, chordal shortening in 14, chordal transposition in five, chordal shortening and reinforcement with artificial chordae in four, leaflet folding plasty in six, and resection-suture in four. Results: Follow-up was complete with an average of 89 ± 59 months (range 1–201 months). In the early postoperative period, transthoracic echocardiography was performed in all patients. The grade of regurgitation was trivial (Grade I) in 17 patients (34.7%) and mild (Grade II) in seven patients (14.3%). Survival rate at 10 and 15 years was 95.2% and 88.9%, respectively. Freedom from reoperation at 10 and 15 years was 95.8% and 89.0%, respectively. Conclusions: The long-term results of mitral valve repair for anterior leaflet prolapse are satisfactory, with low mortality and morbidity. In particular, chordal replacement using temporary Alfieri stitch is a simple and effective procedure.     

Influence of anterior mitral leaflet second-order chordae on leaflet dynamics and valve competence

BACKGROUND: Chordal transposition is used in mitral valve repair, yet the effects of second-order chord transection on valve function have not been extensively studied. We evaluated leaflet coaptation, three-dimensional anterior mitral valve leaflet shape, and valve competence after cutting anterior second-order chordae. METHODS: In 8 sheep radiopaque markers were affixed to the left ventricle, mitral annulus, and leaflets. Animals were studied immediately with biplane videofluoroscopy and echocardiography before (Control) and after (Cut2) severing two anterior second-order "strut" chordae. Leaflet coaptation was assessed as separation between leaflet edge markers in the midleaflet and near each commissure (anterior commissure, posterior commissure). Anterior leaflet geometry was determined 100 milliseconds after end-diastole from three-dimensional coordinates of 13 markers. RESULTS: Anterior leaflet geometry changed only slightly after chordal transection without inducing mitral regurgitation. Leaflet coaptation times were 79+/-17 and 87+/-22 milliseconds at the anterior commissure; 72+/-21, 72+/-19 milliseconds at midleaflet, and 71+/-12 and 75+/-8 milliseconds at the posterior commissure (p = NS) for Control and Cut2, respectively. CONCLUSIONS: Cutting anterior second-order chordae did not cause delayed leaflet coaptation, alter leaflet shape, or create mitral regurgitation. These data indicate that transposition of second-order anterior chordae ("strut" chordae) is not deleterious to anterior leaflet motion per se.     

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.     

Transposition of posterior leaflet for treatment of ruptured main chordae of the anterior mitral leaflet

A 13-year-old girl with mitral regurgitation resulting from rupture of multiple chordae of the anterior leaflet had repair by transposition of a part of the posterior leaflet to the free edge of the anterior mitral cusp. Postoperative clinical hemodynamic, and angiographic studies showed perfect function of the mitral valve. This technique seems to be a good solution for mitral repair in the presence of ruptured anterior mitral chordae.     

Treatment of ruptured or elongated anterior mitral valve chordae by partial transposition of the posterior leaflet: experience with 29 patients

We report a series of 29 patients, 5 to 75 years of age (mean age, 31.8 +/- 21.4 [SD] years), with pure mitral regurgitation caused by ruptured or elongated chordae of the anterior mitral leaflet. These patients underwent mitral valve repair by segmental transposition of the posterior leaflet with its attached chordae sutured to the free edge of the flail anterior leaflet. There were 2 hospital deaths. Follow-up ranged from 1 to 35 months (mean follow-up, 14.9 +/- 8.5 months). One patient is lost to follow-up. Two patients are in New York Heart Association Functional Class II; all others are in Class I. In 17 patients there is no detectable murmur; in 5 patients a mild to moderate systolic murmur can be detected, while 4 have a marked systolic murmur. The adequacy of the repair could be confirmed by Doppler echocardiography, which has shown no evidence of prolapse in 22 patients. A mild regurgitation jet is present in 4 patients, and a marked jet, in 3. Postoperative cardiac catheterization performed in 5 patients has confirmed the Doppler echocardiographic findings. Although longer follow-up is necessary, this technique appears adequate for repairing a major prolapse of the anterior leaflet caused by multiple ruptured or elongated chordae, therefore obviating the need for a prosthetic valve substitute.     

Failed mitral valve repair caused by polypropylene suture

A 65-year-old man with degenerative mitral valve disease had mitral valve repair consisting of posterior leaflet resection and leaflet repair with polypropylene suture and annuloplasty. Six years later, he presented with recurrent mitral regurgitation. The cut tail of a polypropylene suture used at the initial repair had eroded the free edge of the anterior leaflet and its chordae. Chordal transfer was used to re-repair the valve. Soft, braided suture is preferred for leaflet approximation at mitral valve repair; if polypropylene suture is used, suture tails and knots should be positioned such that they do not come into contact with leaflet tissue.     

Mitral regurgitation due to ruptured chordae tendineae. Early and late results of valve repair

From 1958 through 1980, 131 patients had repair of ruptured chordae tendineae of the mitral valve; 62% were men. Ages ranged from 5 to 70 years (median 57). Chordae to the anterior mitral leaflet were ruptured in 44 patients (34%), to the posterior mitral leaflet in 85 (65%), and to both leaflets in two patients (1%). The mitral valve was repaired by leaflet plication without resection in 116 patients, plication after wedge resection of the unsupported leaflet in six, Ivalon sponge buttress of the posterior leaflet in three, resuspension of chordae in two, and annuloplasty alone in the remaining four. Mitral valve annuloplasty was performed in addition to leaflet repair in 115 patients (88%). Operative (less than 30 days) mortality was 6.1%. Survival rate of patients dismissed from the hospital was 92% at 5 years and 73% at 10 years. There were no differences in late survival or risk of reoperation for recurrent or residual mitral insufficiency between patients with ruptured chordae to the anterior leaflet and those with ruptured chordae to the posterior leaflet. Survival was significantly better for the group with repair than it was for a group that underwent mitral valve replacement for ruptured chordae during this same time interval (5 year survival rate, 92% versus 72%, p less than 0.003). The incidence of thromboembolism after repair was 1.8 episodes/100 patient-years compared with 8.0 episodes/100 patient-years after replacement. Our data indicate that valvuloplasty is the procedure of choice for most patients with mitral regurgitation owing to ruptured chordae tendineae, including selected patients with ruptured chordae to the anterior leaflet.     

腱索转移与人工腱索在复杂二尖瓣前叶脱垂病变治疗中的应用

目的总结腱索转移和人工腱索技术在二尖瓣成形术中的临床应用经验,以提高临床治疗效果。方法回顾性分析2008年1月至2013年2月采用腱索转移和人工腱索技术治疗以二尖瓣前叶脱垂为主（均为退行性二尖瓣关闭不全）74例患者的临床资料,其中男34例,女40例,年龄22～64（48．00±6．40）岁。按手术方法不同将74例患者分为两组,腱索转移组（n=42）：行腱索转移术,采用后叶腱索转移至前叶的方法;人工腱索组（n=32）：行人工腱索术,采用的是线圈技术。术后观察围术期死亡、并发症发生情况和二尖瓣反流程度。随访期间行超声心动图观察左心室射血分数、左心室舒张期末内径、收缩期末内径等指标变化。结果腱索转移组和人工腱索组均无围手术期死亡,2例开胸止血,9例术后出现阵发性心房颤动,给予静脉滴注胺碘酮处理后好转。出院前复查心脏超声心动图提示：腱索转移组患者有少量反流5例,微量反流12例,未见明显反流25例。人工腱索组有少量反流6例,微量反流15例,未见明显反流11例。随访70例,随访率94．59％（70／74）。两组患者术后6个月左心室射血分数分别较出院前明显增加（腱索转移组：64．00％±4．20％VS．55．00％±5．10％;人工腱索组：63．00％±3．50％vs．56．00％±4．20％）,左心室舒张期末内径[腱索转移组：（47．00±2．20）mm vs ．（58．00±6．90）mm;人工腱索组：（45．00±3．80）mm vs．（57．00±5．10）mm]、收缩期末内径分别较术前明显缩小（P〈0．05）。腱索转移组术前、出院前、术后6个月左心室射血分数、左心室舒张期末内径、收缩期末内径与人工腱索组差异均无统计学意义（P〉0．05）。腱索转移组术后14个月有1例患者因二尖瓣大量反流再次行二尖瓣置换术。人工腱索组有1例患者于术后6个月由于频繁出现血红蛋白尿再次行二尖瓣置换术。结论腱索转移和人工腱索技术均适合复杂二尖瓣前叶脱垂的处理,人工腱索技术适用范围更为广泛,腱索转移的技术要求更高,变化性较大。两种方法均有良好的近期效果,值得临床掌握和应用。     

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.     

线圈法人工腱索植入治疗二尖瓣关闭不全的近中期疗效分析

目的 总结线圈法人工腱索植入治疗二尖瓣脱垂导致的瓣膜关闭不全的临床经验。 方法 北京安贞医院心外科2008年1月至2011年8月应用线圈法人工腱索植入治疗二尖瓣关闭不全的患者共22例,男15例、女7例,年龄26～69 （53.1±8.5） 岁。心功能分级（NYHA） Ⅱ级6例,Ⅲ级16例。前叶腱索断裂14例,前叶腱索延长2例,前后叶腱索均有断裂4例,后叶腱索断裂2例。均合并重度以上二尖瓣反流,1例合并三房心,1例合并冠心病。左心室舒张期末内径49～67 （58.1±3.9） mm,射血分数（EF） 58%～69% （61.8%±6.1%）,心胸比率0.53±0.16。应用自制的腱索测量器,测量病变腱索邻近正常腱索的长度作为人工腱索的长度,根据瓣叶脱垂的范围,在测量器上制作人工腱索线圈数根,然后将其固定在相应乳头肌和脱垂瓣叶游离缘,常规进行瓣环成形。同期行三房心矫治术1例,冠状动脉旁路移植术1例。所有患者出院后华法林抗凝治疗3个月。 结果 无手术死亡,术后出现血红蛋白尿1例,伤口感染1例,经治疗后均痊愈。出院前超声心动图提示无反流或微量反流1例,微量反流21例。术后左心室舒张期末内径43～53 （48.3±2.1） mm,较术前明显改善。术后门诊随访4～39 （18.3±5.2） 个月,少量反流5例,无或微量反流17例。心功能分级（NYHA） Ⅰ级17例,Ⅱ级5例,较术前明显改善。 结论 线圈法人工腱索植入治疗二尖瓣脱垂所致的二尖瓣关闭不全,手术操作简单易行,近中期疗效满意。     

A case report on the repair of an anterior mitral leaflet chordal rupture using PTFE suture

Surgical repair of ruptured or elongated chordae tendineae of the mitral valve is one of the most complex reconstructive techniques in cardiac surgery. Various surgical procedures have been described to repair chordal abnormalities of the anterior leaflet of the mitral valve. This case report describes a simple repair technique with a double-armed, pledge-supported, expanded polytetrafluorethylene (PTFE) suture. A 48 year-old-man who had mitral regurgitation due to ruptured chordae tendineae of the anterior mitral leaflet underwent successful chordal reconstruction using 3--0 PTFE suture. Mitral regurgitation was completely repaired as shown by left ventriculogram and echo cardiogram more than one year postoperatively. In this experience, this procedure could be used to treat both elongated and ruptured chordae tendineae.     

Edge to edge repair for mitral regurgitation in a patient with chronic hemodialysis: report of a case

In a patient with chronic hemodialysis, the high risk of calcific degeneration of biological prosthetic valve and anticoagulant related complications after valve replacement have been reported. A 71-year-old woman with hemodialysis underwent the edge to edge repair combined with ring-annuloplasty for mitral regurgitation caused by the anterior leaflet prolapse without any torn chordae. Postoperative course was uneventful. There was no significant mitral regurgitation. Double mitral orifices were confirmed by the postoperative echocardiography. A calculated functional mitral valve area was 3.06 cm2. The edge to edge repair is a simplified technique and carried out in a short time. We believe the edge to edge repair is a useful technique for anterior mitral valve prolapse in a patient with chronic hemodialysis.     

Preservation of All Chordae Tendineae and Papillary Muscle During Mitral Valve Replacement with a Tilting Disc Valve

Mitral valve replacement was performed in 21 patients using a surgical technique that preserves the entire papillary muscle and chordal apparatus. With this technique, the anterior mitral leaflet is split from the center of the free edge toward the annulus. Bilateral incisions are made from the proximal end of this split to the two mitral commissures, detaching the anterior leaflet from the annulus. These two halves of the leaflet, with all chordae intact (corresponding to the anterolateral and posteromedial papillary muscles), are judiciously trimmed to remove areas of leaflet untethered by chordae tendineae and (when necessary) fibrous thickening; then swung posteriorly and sutured to the posterior mitral annulus using mattress sutures with pledgets. This surgical technique is expected to favor the preservation of left ventricular function and avoid occurrence of irreversible left ventricular dilation/dysfunction, and has been used successfully for calcific and degenerative etiologies, using both tilting disc valves and porcine bioprostheses. It is especially useful in the implantation of tilting disc and bileaflet mechanical prostheses because anterior subvalvular chordae tissue may interfere with the disc excursion and relocated to the posterior leaflet annulus.