Valve repair for mitral regurgitation due to ruptured chordae tendineae--repaired valve function and late results]

Among 21 consecutive patients with significant mitral regurgitation due to ruptured chordae tendineae operated by an author (K.M.) between March, 1980 and August, 1990, the 18 patients who underwent mitral valve repair were studied to assess the repaired valve function and late results of the repair. The chordal rupture was due to idiopathic degenerative disease in 14 patients, infective endocarditis in three and trauma in one. Patients' ages ranged from 35 to 70 years (mean age 52). Nine patients were in New York Heart Association class II and the remaining nine in class III. In three patients with ruptured chordae of the anterior mitral leaflet, reconstruction of the chordae with xenograft pericardium was performed in two patients and partial closure of a commissure in one. In 15 patients with ruptured chordae of the posterior leaflet, Kay's repair was performed in 13 patients and leaflet resection technique in two. In addition to the chordal and leaflet repairs, Kay's mitral annuloplasty was performed in all. There was no hospital death and all patients showed significant hemodynamic improvement (systolic pulmonary arterial pressure from 43 +/- 20 mmHg preoperatively to 24 +/- 4 mmHg postoperatively, and pulmonary arterial wedge pressure from 17 +/- 10 mmHg to 6 +/- 3 mmHg, p less than 0.001 respectively). The repaired valves showed mild pressure gradient of 3.1 +/- 1.2 mmHg which was significantly lower than the gradient of 6.6 +/- 3.5 mmHg of SJM prostheses. Residual murmur was documented in six patients, in three of whom, however, the murmur disappeared within one year following the operation.(ABSTRACT TRUNCATED AT 250 WORDS)     

Reconstruction of mitral valve chordae and leaflets with one piece of autologous pericardium in extensively destructed mitral valve due to active infective endocarditis

A 20-year-old female patient underwent urgent surgery for extensive mitral valve endocarditis. All marginal chordae and rough zone of A3 leaflet, posterior commissure leaflet, and P3 leaflet down to the annulus became defective after complete debridement of infected tissues. After annular plication, defective leaflets and chordae were reconstructed with a piece of triangular shaped autologous pericardium. Top of the pericardium was directly attached to the posterior papillary muscle, side edges to remnant leaflets, and the base to the annulus, thus substituting for chordae and leaflets at once. No mitral regurgitation was observed during 3 years of follow-up after the operation.     

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.     

Partial tricuspid valve transfer for repair of mitral insufficiency due to ruptured chordae tendineae

BACKGROUND: A new technique is suggested for the reconstructive surgical treatment of mitral regurgitation. It involves partial transfer of the tricuspid valve of the patient to the mitral valve, in order to provide chordae to correct anterior leaflet prolapse of the mitral valve, secondary to rupture of the chordae tendineae. METHODS: From January 1991 to May 1997, 20 patients with mitral insufficiency due to rupture of the chordae were operated on. The prevailing cause was myxomatous degeneration (70%). Patients were in New York Heart Association functional class III and IV. RESULTS: There were no hospital deaths. Two patients were reoperated on. Eighteen patients (90%) are alive with their own valves (class I and II). Doppler echocardiogram mean values were: ejection fraction, 0.65; left atrial diameter, 4.2 cm; mitral area, 2.4 cm2; mitral transvalvular gradient, 3.3 mm Hg. No regurgitation or mild regurgitation was observed in 16 (94.1%) of the 17 cases evaluated. Mean tricuspid valvular area was 3.3 cm2. In all cases, no tricuspid regurgitation was present or it was mild. CONCLUSIONS: Partial transfer of the tricuspid valve to the mitral valve is an effective procedure for the surgical treatment of mitral valve insufficiency secondary to ruptured chordae tendineae of the anterior leaflet.     

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.     

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.     

A new technique for repair of mitral insufficiency caused by ruptured chordae of the anterior leaflet

Prolapse of the anterior leaflet of the mitral valve is the result of ruptured chordae, elongated chordae, or elongated or ruptured papillary muscle. Several techniques have been described for the correction of mitral valve insufficiency. However, when there is severe rupture of the chordae, the most widely accepted solution is valve replacement. We describe a technique for the creation of a neochorda with a strip of tissue from the anterior leaflet of the mitral valve. This technique was used in two patients with severe mitral valve regurgitation. Formation of a neochorda and placement of a Carpentier ring to remodel the anulus obviated the need for a valve replacement. Both patients had an uneventful recovery. Studies performed 3 and 4 months postoperatively showed competent and well-functioning valves. One patient required a valve replacement for acute mitral insufficiency 5 years later, but the other patient was doing well 3 years after the operation. Despite the limited experience, we believe this technique offers a reasonable alternative to valve replacement.     

Clinical experience of mitral valve reconstruction with artificial chordae implantation.

To expand the application of mitral valve reconstruction for pure mitral regurgitation due to diffuse leaflet prolapse, we have employed artificial chordae implantation using GPEP strips in 9 patients and 4-0 PTFE sutures in 20 patients since November 1986. The total number of GPEP strips implanted was 20 with a range from 1 to 4 (average 2.2 per patient) and 45 pairs of PTFE sutures with a range from 1 to 6 (average 2.3 per patient). There was one hospital death (3.4%). All other patients survived operation without valve-related complications except 1 patient who required reoperation for failure of mitral valve reconstruction. In 27 survivors free from reoperation, the amount of mitral regurgitation assessed postoperatively was none or trivial in 19 patients, mild in 7 and moderate in 1. All 27 patients improved to NYHA functional class I or II. So far, our results were no less acceptable than those with conventional procedures for mitral valve prolapse.     

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.     

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.     

二尖瓣脱垂并关闭不全的外科修补

目的：总结二尖瓣脱垂的外科修复经验,方法：对44例二尖脱垂患者的临床资料进行回顾分析。44例患者中风湿性2例,非风湿性42例（22例合并先天性心脏病）,关不全中度24例,重度20例,腱索断裂或缺如12例,腱索过长32例,其中多根腱索过长6例,治疗行腱索移植10例,健索缩短25例（多根腱索短6例）,人工腱索1例,瓣叶折叠3例,瓣叶切除5例,同时行瓣裂缝合8例,瓣环成形28例（后环缝缩14例）,结果：结果：全组无手术死亡病例,1例风湿性患者术后1个月发生左心房血栓再次手术行瓣膜替换,二尖瓣功能正常34例（77．8％）,基本正常6（13．6％）,残留轻至中度关闭不全3例（6．8％）,随访1－18例（平均6．5年）,效果良好,结论：外科修复治疗二尖瓣脱垂是一种安全有效的手术方法。     

Mitral insufficiency due to ruptured chordae tendineae--clinical features, early and late results of valve replacement and repair

To evaluate the early and late results of mitral valve replacement and reconstruction for mitral insufficiency due to ruptured chordae tendineae respectively, 74 consecutive cases were analyzed. Fifty-five (74.3%) of the patients were men, and the mean age was 48 +/- 12 years old (range 16 to 76). The causes of the mitral disease were idiopathic in 50 (67.6%), rheumatic in 7 (9.4%) and infective endocarditis in 11 (14.9%) patients. In idiopathic 50 cases, 24 had mitral valve prolapse and 16 had both mitral valve prolapse and hypertension. Forty-one (55.4%) of the patients were in NYHA functional class III or IV preoperatively. Thirty (40.5%) cases underwent surgery within one year after their initial symptoms of heart failure onsets including six emergency operation cases due to uncontrollable acute lung edema. Chordae to anterior mitral leaflet were ruptured in 31 (a5, m16, p10)[41%] patients, to the posterior mitral leaflet in 45 (a4, m23, p18)[59%], and to both leaflets in one patient. Mitral valve replacement was performed in 68 patients (91.9%) and 6 patients (8.1%) underwent mitral valve repairs. Twenty cases underwent associated procedures that included tricuspid valve annuloplasty in 8, aortic valve replacement in 5 and myocardial revascularization in 4 cases. There were two operative deaths (2.4%); both occurred after replacement, left ventricular rupture in one and DIC in one. Mean follow-up period was 4.5 years (range 1 to 17) in 67 cases. There were four late deaths; all occurred after replacement. However five patients sustained mild mitral insufficiency after mitral valve repair including one that became worse of regurgitation three years after isolated Kay's annuloplasty, there were no cases that had needed reoperation and no late death after reconstruction. Left ventricular function and pulmonary arterial pressure were almost normalized in more than 90% cases postoperatively. Our data indicated that mitral valve reconstruction (McGoon's plus Kay's method as standardized maneuver) was the procedure of choice for selected patients with mitral insufficiency owing to ruptured chordae tendineae to the posterior mitral leaflet, including more limited patients with ruptured chordae to the anterior mitral leaflet.     

Artificial chordae for pediatric mitral and tricuspid valve repair.

OBJECTIVE: To evaluate pediatric atrioventricular valve repair with artificial chordae. METHODS: Between February 2001 and January 2006, artificial chords were used in 21 children with severe mitral or tricuspid valve regurgitation. Patients with AVSD were excluded. Median age was 84 (1-194) months. Five patients had isolated tricuspid valve anomalies, 16 had mitral valve anomalies (associated tricuspid annular dilatation in 4). Tricuspid neochordae were placed to anterior (three patients) and septal (two patients) leaflets. Mitral neochordae were placed to anterior (15 patients) and posterior (1 patient) leaflets. Additional ring annuloplasties were performed in 12 (mitral 11, tricuspid 1), as well as 2 de Vega tricuspid annuloplasties. Patch insertion was used in acute endocarditis (tricuspid one). All echocardiographic studies were reviewed and analyzed by a single cardiologist. RESULTS: No mortality occurred. Follow-up was complete (mean 28+/-18 months). Two patients were reoperated, one for mitral ring dehiscence and one for recurring mitral valve insufficiency. Both valves were replaced by mechanical valve prosthesis. At last follow-up tricuspid insufficiency was mild (three) or moderate (two). Moderate insufficiency occurred due to remaining restriction of the septal leaflet after repair in endocarditis (one) and remaining prolapse of the anterior leaflet (one). Mitral insufficiency was absent (five), mild (seven), or moderate (two). Moderate insufficiency was caused by recurrent anterior leaflet shortening after valve repair in rheumatic valve disease (two). Valve restriction caused by artificial chordae was not found. CONCLUSIONS: Mitral and tricuspid valve repair with artificial chordae in children demonstrated acceptable results. Despite patient growth, valvular restriction by the artificial chordae was not observed ad mid-term follow-up.     

Repair of mitral regurgitation caused by prolapse of the anterior mitral leaflet

Mitral regurgitation caused by prolapse of the anterior mitral leaflet has been considered to be difficult for reconstruction. In Japan, these cases have been repaired mainly by replacement of chordae with artificil sutures. We have repaired them by Carpentier’s technique. We report a series of 9 patients with pure mitral regurgitation caused by ruptured or elongated chordae of the anterior mitral leaflet. Two of them had lesions at both anterior and posterior leaflet. All patients underwent mitral valve repair by segmental transposition of the posterior leaflet. As for associated procedures, there were ring annuloplasty with Carpenter rings (9 cases), sliding technique (8 cases) reported by Carpentier, reinforcement by transposition of secondary chordae of the posterior leaflet (6 cases), commissuroplasty (1 case), and closure of leaflet perforation. All patients survived operations and all patients except one underwent left ventriculography postoperatively. In only 2 patients, residual mitral regurgitatin classed as I/IV was observed. All patients returned home in New York Heart Association class I. Follow-up ranged from 7 to 45 months (mean follow-up 20 months). All patients were free from reoperation or thromboembolism. Although longer follow-up is necessary, this technique appears to be adequate for the repir of patients with anterior leaflet prolapse.     

Kay's mitral valve repair for mitral regurgitation due to ruptured chordae tendineae--clinical and hemodynamic observations

Kay's mitral valve repair was performed in six consecutive patients with symptomatic mitral regurgitation due to ruptured chordae tendineae of the posterior leaflet. All patients including one with mild residual murmur showed a marked decrease in the heart size and significant clinical improvement. Postoperative hemodynamic studies, performed in four patients, showed restoration of normal or near-normal dynamics. The medium-term follow-up, 15 to 30 months after the operation, revealed continuing asymptomatic states in all. The function of the repaired valves was significantly better than that of the Hancock mitral bioprostheses. The advantages of this procedure compared with mitral valve replacement for the same condition were stressed.     

Kay's mitral valve repair for mitral regurgitation due to ruptured chordae tendineae clinical and hemodynamic observations

Kay's mitral valve repair was performed in six consecutive patients with symptomatic mitral regurgitation due to ruptured chordae tendineae of the posterior leaflet. All patients including one with mild residual murmur showed a marked decrease in the heart size and significant clinical improvement. Postoperative hemodynamic studies, performed in four patients, showed restoration of normal or near-normal dynamics. The medium-term follow-up, 15 to 30 months after the operation, revealed continuing asymptomatic states in all. The function of the repaired valves was significantly better than that of the Hancock mitral bioprostheses. The advantages of this procedure compared with mitral valve replacement for the same condition were stressed.     

An infant case of a rupture of chordae tendineae; report of a case

We report a case of 5-month-old boy with severe mitral regurgitation due to a rupture of chordae tendinae. Cardiac echography showed a prolapse of the anterior cusp of the mitral valve. He was progressively deteriorated despite maximal medical treatment, and a surgical intervention was performed 15 hours after the onset. The operative finding was a rupture of chordae tendinae attached to the anterior cusp of the mitral valve. The infant underwent mitral valve plasty using artificial chordae together with partial annulo-plasty. A rupture of chordae tendineae is extremely rare in infants, and its cause is yet unknown. Chordal reconstruction is feasible even at this early stage of life, although the long-term follow-up is mandatory.     

Surgical Application for a Prolapse of the Anterior Mitral Leaflet by Replacing Artificial Chordae with Polytetrafluoroethylene Grafts

Purpose There are an increasing number of reports concerning mitral valve repair by a reconstruction of the chordae tendinae using expanded polytetrafluoro-ethylene (PTFE) sutures. However, little information is available about extended application or results of this technique for an extended prolapse of the anterior mitral leaflets.Methods Between July 1991 and August 2003, 28 patients with moderate to severe mitral regurgitation as a result of a prolapse of anterior leaflets (age range, 15–73 years) underwent mitral valve repair by reconstruction of the artificial chordae with 4-CV expanded polytetrafluoroethylene sutures without a leaflet resection. Either Kay’s suture technique or ring annuloplasty was also performed to correct annular dilatation in all patients.Results No operative death or late mortality was observed. The prolapsed segment, which was successfully repaired, was within 33% of the anterior mitral leaflet (AML) in 6 patients, from 33% to 50% in 5, from 50% to 99% in 11, and 100% in 6 patients. Before discharge, immediate postoperative echocardiography showed less than moderate mitral regurgitation in 28 of 28 patients. The follow-up, consisting of a clinical examination and serial echocardiograms, was complete in all cases and the mean follow-up period was 80.6 months (range, 12–146). There were two failures that required a reoperation because of a worsening mitral regurgitation and hemolytic anemia (elongation of anchored side of papillary muscle). The other two patients required mitral valve replacement due to a progressive regression of the left ventricular function, although the regurgitation worsened from a mild level to a moderate one. When the reoperated patients were excluded from the following data, the degree of mitral regurgitation, estimated by echocardiography performed at recent follow-up period, was none in 10 patients, trivial in 13 patients, and mild in 1 patient. In addition, the systolic and diastolic dimensions of the left ventricle decreased significantly (P < 0.01).Conclusions The replacement of artificial chordae was not complicated and it seemed to help to preserve a good relationship among leaflet tissues, chordae, and papillary muscles. We therefore suggest that the extensive use of PTFE artificial chordae appears to be a promising procedure for the repair of all kinds of mitral lesions causing mitral regurgitation.     

Mitral valve repair for active infectious endocarditis

Between December 2005 and November 2011, 11 patients with mitral valve regurgitation (MVR) resulting from native valve endocarditis underwent mitral valve plasty (MVP). These patients were aged 44.4 ± 11.3 years. The mean follow-up period of the patients was 3.1 ± 0.63 years. Five patients were men. Emergency or urgent surgery was required in 5 patients. Three patients were categorized as New York Heart Association( NYHA) functional class IV. Infection of the mitral valve, occurred in the anterior leaflet in 3 patients, the posterior leaflet in 5 patients, and the anterior-posterior leaflet in 3 patients. Nine patients had a resection suture technique. One patient had chordae replacement with expanded polytetrafluoroethylene (ePTFE), and 1 patient had replacement using the pericardium. All patients received ring annuloplasty with a partial flexible ring. After surgery, all patients were categorized as NYHA functional class I. There were no valve associated complications, no hospital deaths, no late deaths, and no reoperations. We conclude that MVP is an effective treatment for active infective endocarditis( AIE) with mitral regurgitation.     

Pre-measured artificial chordae for mitral valve repair

There is growing interest in the application of artificial chordae to correct mitral valve regurgitation caused by prolapse. Application of pre-measured artificial chordae facilitates creation of chordae of appropriate length. Herein we illustrate the technique for creation of pre-measured artificial chordae, documenting neo-chordal length and number in 50 patients with anterior leaflet prolapse, highlighting the need for chordae of more than one length in 14% of patients.