Eur J Cardiothorac Surg 2003;24:653-655
© 2003 Elsevier Science NL
Simplified chordal reconstruction: ‘oblique’ placement of artificial chordae tendineae in mitral valve replacement
Yoshiharu Soga,
Kazunobu Nishimura,
Kazuhiro Yamazaki,
Masashi Komeda*
Department of Cardiovascular Surgery, Kyoto University Graduate School of Medicine, 54 Shogoinkawahara-cho, Sakyo-ku, Kyoto 606-8507, Japan
Received 3 June 2003;
received in revised form 11 July 2003;
accepted 17 July 2003.
* Corresponding author. Tel.: +81-75-751-3780; fax: +81-75-751-4960
e-mail: masakom{at}kuhp.kyoto-u.ac.jp
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Abstract
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We describe a novel chordal-sparing technique of mitral valve replacement using minimum number of artificial chordae tendineae in patients with rheumatic mitral stenosis. Continuity between the papillary muscles and mitral annulus is restored by placing two 3-0 expanded polytetrafluoroethylene mattress sutures: one for the anterior papillary muscle at the 9–10 o'clock position (as defined by mid-anterior annulus to be 0 o'clock) on the mitral annulus, and the other for the posterior papillary muscle at the 5–6 o'clock position.
Key Words: Rheumatic mitral stenosis • Artificial chordae tendineae • Valve replacement • Oblique direction
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1. Introduction
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Preservation of the chordae tendineae (CT) and papillary muscles (PM) in mitral valve replacement (MVR) has been known to enhance left ventricular (LV) function after MVR in patients with mitral regurgitation [1–3]. In patients with mitral stenosis (MS), however, the diseased subvalvular apparatus often needs to be resected, resulting in discontinuity between the PM and the mitral annulus and possible LV dysfunction. One solution is to apply artificial CT, such as expanded polytetrafluoroethylene (ePTFE) sutures, to achieve continuity between the PM and the mitral annulus [4,5]. However, the optimal direction of alignment of the artificial CT has not been clearly defined. In a previous study we compared several directions of alignment of artificial CT in normal canine hearts and reported that an ‘oblique’ direction best enhanced systolic LV function, possibly by supporting LV twist and diastolic recoil [6,7]. We have applied this method clinically to human patients since 1998, and report our technique and findings below.
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2. Technique
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A longitudinal right-side left atriotomy is made as a conventional approach to the mitral valve. After resection of both the anterior and posterior mitral leaflets and subvalvular apparatus (Fig. 1) , continuity between the papillary muscles and mitral annulus is restored by the placement of two 3-0 e-PTFE mattress sutures. One suture is placed and tied at the tip of the anterior PM and one at the tip of the posterior PM. When the PM tip is not fibrous, buttressed sutures are used instead. The suture for the anterior PM is placed at the 9–10 o'clock position on the mitral annulus (as defined by mid-anterior annulus to be 0 o'clock), and the suture for the posterior PM at the 5–6 o'clock (Fig. 2)
. Because we have found that the distance between the PM tip and the mitral annulus is constant throughout the cardiac cycle in the canine heart [8], we believe that the length of the artificial CT can be determined during intraoperative cardiac arrest, and may be suitable if the sutures are tied just less than taut before insertion of the prosthesis. After completion of the valve replacement, the motion of the prosthetic leaflets is carefully examined to ensure that the leaflets are not entrapped by the 3-0 e-PTFE sutures. For this purpose, transesophageal echocardiography is also used before as well as immediately after the extra-corporeal circulation is discontinued.
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Fig. 1. The anterior mitral leaflet is resected and the fused chordae are transected at their insertions on the papillary muscles. Then the posterior leaflet, with the exception of the basal chordae, is resected.
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Fig. 2. A 3-0 e-PTFE mattress suture is placed at the tips of the anterior and the posterior PM. When the PM tip is not fibrous, 3-0 e-PTFE buttressed mattress sutures are used instead. The suture for the anterior PM is placed at the 9–10 o'clock position (not at the 2 o'clock) on the mitral annulus, and the suture for the posterior PM at 5–6 o'clock. The sutures are tied just less than taut before insertion of the prosthesis. (AV, aortic valve).
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3. Comment
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In 1990, Bernhard and associates introduced a technique to reconstruct continuity between the PM and mitral annulus during MVR by placing 3-0 ePTFE sutures between the PM tip and the sewing ring of a mechanical valve [4]. Okita and coworkers reported good mid-term results of chordal-sparing MVR using ePTFE sutures in patients with MS, and showed that the postoperative LV ejection fraction (LVEF) after chordal-sparing MVR was better than that in patients after conventional MVR [5]. They placed four ePTFE sutures – at the 2, 4, 8, and 10 o'clock positions – on the mitral annulus. In 1995, we introduced the notion that an ‘oblique’ direction (anterior PM chordae aligned in an anterior direction and posterior PM chordae aligned in a posterior direction) enhanced systolic LV function and gave better results than the use of the anterior, posterior, and counter directions [5]. On the basis of these experimental results, since 1998 we have applied this method using only two sets of ePTFE sutures (i.e. four arms in total) to human patient, with minor modification from the original one [6]: the 3-0 e-PTFE suture for the anterior PM was transferred to the 9–10 o'clock position from the 2 o'clock position on the mitral annulus in order to avoid possible problems associated with placing the artificial CT in the LV outflow. One of the potential merits of the ‘oblique’ method is that it may reduce the risk of the future event of thromboembolism, since the simple method minimize the number of the artificial chordae yet with providing significant hemodynamic merits.
This ‘oblique’ method has been used so far in 19 patients with MS at our institution. In 18 patients the mitral valve was replaced by a St. Jude Medical mechanical prosthesis using non-everting 2-0 polyester stitches, and in the other patient a Hancock II bioprosthesis was used. There was no mortality or major morbidity. Echocardiographic studies during the follow-up period showed no evidence of prosthetic valve dysfunction or paravalvular leakage. LVEF late after the operation (mean 14 months, 68±2%) was better than that in the early period (mean 23 days; 61±2%, P<0.01), and comparable to the preoperative level (64±2%). Postoperative LV end diastolic diameter (44.4±1.4 mm) was maintained as the same level as preoperatively (45.2±1.6 mm). All patients are alive and doing well.
The ‘oblique’ method can be used safely with minimal number of artificial chordae, and may be effective for preservation of LV function after MVR in patients with rheumatic mitral stenosis.
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Footnotes
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Presented in part at the 51st International Congress of the European Society for Cardiovascular Surgery, Helsinki, Finland, 28 June–1 July, 2002.
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References
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- Lillehei C.W., Levey M.J., Bonnabeau R.C. Mitral valve replacement with preservation of the papillary muscles and the chordae tendineae. J Thorac Cardiovasc Surg 1964;47:532-543.
- David T.E., Burns R.J., Bacchus C.M., Druck M.N. Mitral valve replacement for mitral regurgitation with and without preservation of chordae tendineae. J Thorac Cardiovasc Surg 1984;88:718-725.[Abstract]
- Komeda M., David T.E., Rao V., Sun Z., Weisel R.D., Burns R.J. Late hemodynamic effect of the preserved chordal attachment. Circulation 1994;90(Suppl. II):II190-II194.
- Bernhard A., Sievers H.H., Nellesen U., Maurer I. Improved mitral valve replacement. Eur J Cardiothorac Surg 1990;4:224-225.[Abstract]
- Okita Y., Miki S., Ueda Y., Tahata T., Sakai T., Matsuyama K. Mitral valve replacement with maintenance of mitral annulopapillary muscle continuity in patients with mitral stenosis. J Thorac Cardiovasc Surg 1994;108:42-51.[Abstract/Free Full Text]
- Komeda M., DeAnda A., Glasson J.R., Bolger A.F., Tomizawa Y., Daughters G.T., Tye T.L., Ingels N.B., Miller C. Exploring better methods to preserve the chordae tendineae during mitral valve replacement. Ann Thorac Surg 1995;60:1652-1658.[Abstract/Free Full Text]
- Komeda M., DeAnda A., Glasson J.R., Daughters G.T., Bolger A.F., Nikolic S.D., Ingels N.B., Miller C. Improving methods of chordal-sparing mitral valve replacement – Part III: optimal direction for artificial chordae. J Heart Valve Dis 1996;5:484-490.[Medline]
- Komeda M., Glasson J.R., Bolger A.F., Daughters G.T., Ingels N.B., Miller D.C. Papillary muscle – left ventricular wall ‘complex’. J Thorac Cardiovasc Surg 1997;113:292-301.[Abstract/Free Full Text]
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Abstract
1. Introduction
