Mitral valve replacement with preservation of whole papillary muscles and chordae tendineae

A total of 20 patients underwent mitral valve replacement (MVR) with preservation of the papillary muscles (PM) and chordae tendineae (CT) with the object of maintaining left ventricular contractility and decreasing the risk of left ventricular rupture after surgery. The patients comprised of 8 males and 12 females whose ages ranged from 33 to 67 years. In 8 patients, the posterior leaflet was left in place and in 12, the CT to the anterior leaflet were also preserved by excision of the central portion and reattachment of the rest of the leaflet to the appropriate commissural regions. St. Jude Medical valves were exclusively employed as a substitute. Reasons for MVR were isolated MR in 12 cases, MRs in 5 and MSr in 3. There were one operative, one hospital and one late death respectively. Postoperative C.I. increased from 2.65 +/- 0.48 to 3.8 +/- 0.75 ml/min./M2 and LVEF increased from 55.1 +/- 11.4 to 63.4 +/- 13.4%. The area method showed marked improvement of segmental wall motion in anterolateral regions. Chordal shortening also disclosed improvement in long axis. Preservation of papillary muscles and chordae tendineae during MVR has been found to have a beneficial effect on postoperative left ventricular contractility.     

Mitral valve replacement with preservation of the posterior leaflet, chordae tendineae and papillary muscles (modified MVP)

The modified MVR leaving the posterior leaflet and its subvalvular tissues intact was performed in 40 patients including 17 of MR, 17 of MSR and 6 of MS from 1981 to 1984 in this institution. Mitral valves were replaced mostly with mechanical valves and using interrupted everting mattess sutures. Moreover, the aortic valve was simultaneously replaced in 13 patients and the tricuspid valve was also treated with annuloplasty, commissurotomy or replacement in 11 patients. There were no hospital deaths and 3 late deaths caused by MOF or unknown cause. Left ventricular rupture as a fatal complication did not occur. High cardiac index and LVSWI with low left atrial pressure were maintained in the immediate postoperative period. Q-d times at the base, mid portion and apex of the left ventricle were measured by 2-D echocardiograms in the follow-up period and were compared with those of patients with conventional MVR. Those at apex and mid portion were significantly shorter in patients with modified MVR than in patients with conventional MVR. These findings suggest that the left ventricular contraction might be maintained better in the former than in the latter. In conclusion, preservation of the posterior leaflet, chordae tendineae and papillary muscles should be preferable in MVR for prevention of both LOS and left ventricular rupture.     

Ruptured papillary muscle after mitral valve replacement with preservation of chordae tendineae

We report a new technique of left coronary artery implantation to the aorta with interposition of a tube created from the great arterial wall for anomalous left coronary artery from pulmonary artery. This technique was used in 3 patients, of which 2 patients survived. It achieves two coronary artery repair and avoids problems related to extensive mobilization of coronary artery for translocation. It is easily reproducible.     

Mitral valve repair by replacement of chordae tendineae with polytetrafluoroethylene sutures

Expanded polytetrafluoroethylene sutures have been used for replacement of diseased chordae tendineae during reconstructive procedures on the mitral valve in 43 patients. There were 28 men and 15 women whose mean age was 55 years, range 21 to 76. Three fourths of the patients were in New York Heart Association class III or IV. Replacement of primary chordae tendineae of the anterior leaflet was performed with 4-0 or 5-0 polytetrafluoroethylene sutures. A double-armed suture was passed twice through the fibrous portion of the papillary muscle head and tied down. Each arm of the suture was brought up to the free margin of the leaflet and passed through the area where the native chorda was attached. After the lengths of the two arms were adjusted, the ends were tied together on the ventricular side of the leaflet. Thirty patients had degenerative disease of the mitral valve; the incompetence was due to prolapse of the anterior leaflet in 14 patients and prolapse of the anterior and posterior leaflets in 16. Eleven patients had rheumatic mitral valve disease: four had stenosis, three had regurgitation, and four had mixed lesions. Two patients had ischemic mitral regurgitation caused by rupture of a papillary muscle head. There were no operative deaths. Patients have been followed up from 5 to 61 months, mean 13. Doppler echocardiographic studies were performed at regular intervals after the operation and revealed normal mitral valve function in most patients There were two failures that necessitated mitral valve replacement: one because of acute mitral regurgitation and the other because of hemolysis. There have been two late deaths, neither one valve related. Replacement of chordae tendineae with polytetrafluoroethylene sutures is simple and allows for reconstruction of the mitral valve in many patients who would otherwise require mitral valve replacement. Because our patients have been followed up for a limited time, the long-term results of this procedure remain unknown.     

Mitral valve prosthesis with preservation of the chordae and papillary muscles in patients with mitral insufficiency

Mitral valve (MV) prosthetics was performed in 14 patients in its insufficiency. In MV replacement the chordopapillary apparatus (CPA) of the posterior cusp was left intact. The EMIKS or LIKS disk prosthesis was implanted in most cases (6 and 6 patients, respectively), the biological BAKS prosthesis was implanted in 2 patient. Orientation of the large semicircumference in the direction of the anterior or posterior commissure was the optimal orientation for the disk prostheses. Measurement of the parameters of hemodynamics on the operating table showed that reduction of the rigidity of the left-ventricular myocardium and the increase of the stroke index in patients with an intact chordopapillary apparatus of the posterior cusp differed significantly from those in patients with completely excised MV. Preservation of the CPA during MV replacement in patients with mitral insufficiency leads to reduction of the rigidity of the left-ventricular myocardium and improvement of its function immediately on the operating table.     

Mitral valve replacement with preservation of chordae tendinae: rationale and technical considerations

Mitral valve replacement with preservation of chordae tendinae and papillary muscles may preserve postoperative left ventricular function better than conventional mitral valve replacement in patients with chronic mitral regurgitation. The technical aspects and the rationale for mitral valve replacement with preservation of chordae tendinae are reviewed.     

An unusual lethal complication of preservation of chordae tendineae in mitral valve replacement

In two patients, several chordae tendineae of the mural leaflet were preserved during mitral valve replacement. Hemorrhagic necrosis and spontaneous rupture of the preserved posterior papillary muscle led to disc entrapment and the death of both patients.     

乳头肌瓣环固定后的二尖瓣置换术

目的　为了提高二尖瓣置换术的疗效和远期效果 ,总结保留二尖瓣瓣下结构以维持动力环完整性的经验。　方法　 2 0 0 0年 1月至 2 0 0 2年 2月 ,对 130例心瓣膜置换术患者采用将乳头肌缝合固定于瓣环下的方法 ,并根据二尖瓣主要病变类型将其分为 3组 :二尖瓣关闭不全组 (MI组 )、二尖瓣狭窄组 (MS组 )、主动脉瓣和二尖瓣双瓣膜置换术组 (DVR组 )。术后用二维超声心动图测量升主动脉内径 (AD)、右心室舒张期内径 (RVIDd)、右心房内径(RAD)、左心室舒张期内径 (L VIDd)、左心房内径 (L AD) ,比较各组手术前后的效果。　结果　 MI组术后 L VIDd、L AD均较术前明显缩小 (P<0 .0 1) ,RAD与术前比较无明显变化 ;DVR组 RAD、L VIDd、L AD明显缩小 (P<0 .0 1) ;MS组 RVIDd、L AD明显缩小 (P<0 .0 1) ,L VIDd较术前无明显变化。全组住院死亡 1例 ;随访 12 9例 ,死亡 3例 ,其余12 6例术后心功能达 级和 级。　结论　二尖瓣置换术时 ,将左心室乳头肌固定于瓣环下 ,可保持乳头肌瓣环的连续性 ,最大程度地改善心瓣膜置换术后心脏功能。     

Mitral regurgitation after myocardial infarction. Coronary artery bypass grafting and mitral valve replacement with chordae preservation.

A patient with acute ischemic mitral regurgitation after acute myocardial infarction required emergency coronary artery bypass grafting and mitral valve replacement with chordae preservation. For severe mitral regurgitation and heart failure due to myocardial infarction and ischemic papillary muscle dysfunction, mitral valve replacement with chordae preservation was effective. Here, we discuss the etiology of ischemic mitral regurgitation and the operative method for valve repair or replacement.     

Analysis of left ventricular motion after mitral valve replacement with a technique of preservation of all chordae tendineae. Comparison with conventional mitral valve replacement or mitral valve repair.

The postoperative regional left ventricular motion of 22 patients with a diagnosis of mitral regurgitation, and who underwent mitral valve replacement with preservation of chordae tendineae, were retrospectively analyzed by cineangiography in the early postoperative period and by multiple-gated cardiac blood pool scintigraphy in the mid-to-late postoperative period. The operation consisted of the division of the anterior leaflet into anterior and posterior segments, the shifting and reattachment of the divided segments to the mitral ring of the respective commissural areas, and the use of a low-profile bileaflet prosthetic valve. Control groups consisted of 28 patients with mitral regurgitation who underwent mitral valve replacement with a conventional technique and 16 patients who underwent mitral valve repair. Compared with the conventional mitral valve replacement group, the radial shortening of the left ventricle of the chordae-preserved mitral valve replacement group was greater at the apical septal, inferoapical, anterobasal, and anterolateral portions, whereas the radial shortening of the repair group was greater than that of the chordae-preserved group only at the inferolateral portion. The ejection fraction of the whole left ventricle was statistically greater in the chordae-preserved group, and also regional ejection fraction of the chordae-preserved mitral valve replacement group was greater at the apical septal, inferoapical, inferolateral, anterobasal, and anterolateral portions than that of the conventional mitral valve replacement group at these portions. On the other hand, the postoperative regional and global motion was identical to that of the mitral valve repair group except at the inferolateral portion. The result of this study supports a concept that maintenance of continuity between the mitral anulus and the papillary muscle has a beneficial effect on postoperative left ventricular performance.     

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.     

Mitral valve replacement with preservation of ventricular annular continuity

We evaluated clinical effects of mitral valve replacement with preservation of ventricular annular continuity in 53 patients with isolated mitral stenosis and regurgitation. The patients were divided into 3 groups; Group 1: the patients had conventional mitral valve replacement, Group 2: with preservation of posterior leaflet ventricular annular continuity (VAC) (33 patients), and Group 3: preservation of both anterior and posterior leaflet (8 patients). Operative technique was described for pure mitral regurgitation and mitral stenosis. There was one patient died within 30 days operatively in each group. In Group 1 the patient died for poor LV function, in Group 2, the patient died for postoperative GVHD, and in Group 3, the death caused by postoperative LV rupture. We have observed no late death. Minor thromboembolization in early stage were seen in 2 cases of Group 2 and there were no apparent correlation with operative technique. Postoperative cardiac catheterization data (Pulmonary Artery wedge pressure, C.O, LVEF, LVEDV1) showed no significant difference among these 3 groups. Segmental wall contraction in left ventriculography demonstrated good contraction in Group 2 and Group 3 compared with that of Group 1. Left ventricular contraction index with heart rate corrected mean Vcf (Vcfc) and left ventricular end-systolic wall stress (sigma es) relation using two dimensional cardiac echogram demonstrated almost normal range in the groups 2 and 3. These findings suggests that mitral valve replacement with preservation of ventricular annular continuity has beneficial effects on postoperative left ventricular function and requires to be further investigated.     

Replacement of ruptured chordae tendineae of the mitral valve with autologous pericardial chordae.

Severe mitral regurgitation owing to rupture of chordae tendineae has been repaired in 10 patients by construction of new chordae from autologous pericardium. The site of rupture was the posterior leaflet in eight patients, the anterior leaflet in one patient, and both leaflets in one patient. Cardiac catheterization demonstrated severe mitral regurgitation (average 49%) and a left atrial V wave of 45 mm. Hg. The reconstruction was carried out with pericardium rolled into a chorda with one end attached to the appropriate papillary muscle and the other attached to the flail edge of the mitral valve leaflet being repaired. One patient died on the seventh postoperative day from pneumonia. The remaining nine patients are alive and well (Functional Class I) from 6 months to 9 1/2 years (average 3 years) following the operation. None requires anticoagulants.     

Generation of chordae tendineae with polytetrafluoroethylene stents. Results of mitral valve chordal replacement in sheep

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 with unpredictable results. Mitral valve replacement is usually recommended in that situation. This report describes a simple repair technique that we have devised. We resected one or two marginal chordae of the anterior leaflet of the mitral valve in 35 sheep and replaced them with a double-armed, pledget-supported, expanded polytetrafluoroethylene suture. The 30 surviving animals were studied hemodynamically and were electively put to death 3, 6, 9, 18, and 24 months after the operation. Mitral insufficiency did not develop in any of the sheep. All specimens had a normal mitral valve without thrombosis. The polytetrafluoroethylene suture remained pliable and was incorporated into the anterior leaflet and papillary muscle. Scanning and transmission electron microscopy showed that the suture was completely covered by a sheath of tissue with a collagen structure remarkably similar to that of a native chorda. Calcification was not detected in the new chordae. This reproducible and safe technique may considerably simplify the difficult repair of chordal abnormalities.