Eur J Cardiothorac Surg 2007;31:550-551. doi:10.1016/j.ejcts.2006.12.004
Copyright © 2007, European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved
Posterior transposition of anterior leaflet for complete chordal preservation
Rafael García Fuster*,
Ignacio Rodríguez,
Vanesa Estevez,
Alejandro Vazquez
Department of Cardiac Surgery, University General Hospital of Valencia, Valencia, Spain
Received 22 September 2006;
received in revised form 4 December 2006;
accepted 6 December 2006.
* Corresponding author. Address: C/ Artes Gráficas no. 4, esc. izda, pta 3, 46010 Valencia, Spain. Tel.: +34 963622216; fax: +34 963862982. (Email: rgfuster{at}terra.com).
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Abstract
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A method of complete chordal preservation based on posterior transposition of anterior leaflet is presented. The anterior leaflet and chordae are completely detached from the annulus and reimplanted as a large patch under the posterior leaflet. The excess tissue without chordae is excised and the remnant with all the chordae is plicated by sutures used to implant the prosthesis. The posterior leaflet is left intact. The technique is safe and reproducible and no complications related with the procedure have been observed at mid-term follow-up. These results have led to a wider application of total chordal preservation during mitral valve replacement.
Key Words: Mitral valve • Mitral valve replacement
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1. Introduction
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Total chordal preservation in patients undergoing mitral valve replacement (MVR) may improve clinical outcome although the real benefit remains unclear [1,2]. However, most surgeons retain only the posterior leaflet with chordae tendinae because of concerns about potential complications with complete preservation: interference with prosthetic mechanism, left ventricular outflow tract obstruction, need to undersize the prosthesis or higher technical complexity with longer surgical time [2–4]. A variety of techniques have been reported to overcome these limitations with different advantages and disadvantages [5–8].
We present our experience with a simple mitral valve sparing procedure based on the entire detachment of anterior leaflet with all the chordae and posterior reattachment under the posterior leaflet.
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2. Technique
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The procedure is performed via median sternotomy and the mitral valve is reached through a left atrial incision behind the interatrial groove or by means of a transeptal approach. The anterior leaflet is incised at its base and completely detached from the annulus. This incision is carried to both commissures and the leaflet is widely mobilized (Fig. 1
). Careful leaflet and chordae decalcification may be performed in this stage. Then it is reimplanted as a large patch under the posterior leaflet with 3 or 4 U stiches and its basal portion without chordae is trimmed to remove excess tissue (Fig. 1). The remnant with all the chordae is resuspended and plicated on the mitral annulus by sutures used to secure the prosthetic valve (Fig. 2
). The posterior mitral leaflet is left intact and the prosthesis is implanted in a standard fashion.
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Fig. 1. Schematic drawing of the management of the anterior leaflet with this technique of complete chordal preservation. The anterior leaflet is incised at its base and completely detached from the annulus. Then it is reimplanted under the posterior leaflet.
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We have used this technique in 46 patients since April 2002, most of them suffering a rheumatic valve disease. Fifteen patients underwent combined mitral and aortic valve replacement. Bioprostheses (Carpentier-Edwards Perimount and Magna) and bileaflet mechanical prostheses (Bicarbon, St Jude and On-X valves) have been implanted and all the patients had uneventful postoperative recovery with no complications related with the procedure at mid-term follow-up.
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3. Comment
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The deleterious effect of the loss of annulo-ventricular continuity has been documented by a large number of studies and preservation of left ventricular function has become an important concern after MVR. Chordal preservation has gained popularity and is now a standard procedure [1,2]. Although a wide variety of techniques have been described for total chordal preservation, most surgeons retain only the posterior leaflet. These techniques differ primarily in the location where the anterior leaflet and chordae are inserted in the mitral annulus [3,5–8]. The procedure described here is easy to perform and solves the two primary problems generally encountered with chordal preservation during MVR: interference with the prosthesis and left ventricular outflow tract obstruction. The first complication is prevented by plication of the trimmed anterior leaflet with all the chordae on the mitral annulus by sutures used to secure the prosthetic valve. By detaching completely the leaflet from the annulus, tension between the two commissures is released and restriction of leaflet is prevented and thus, redundant tissue does not protrude after good plication. The second problem is obviated by the posterior reimplantation avoiding the anterior annulus and the antero-lateral commissure. Excess tissue reimplanted anteriorly might protrude into the left ventricular outflow tract and is a potential limitation of some techniques [5–8]. Sintek and colleagues [5] recommended the reimplantation of two or four segments of anterior leaflet in an anterior anatomical position (Khonsari I technique), but this procedure is time-consuming requiring prolonged aortic clamping time.
Other important advantages of our technique can be considered: reinforcement of posterior atrioventricular groove preventing catastrophic complications such as myocardial rupture and simplified implantation of a prosthesis in a calcified mitral annulus. In this challenging scenario a ‘no touch’ technique of the annulus may be facilitated by the posterior transposition and plication of the anterior leaflet and chordae. Prosthesis sutures can be secured through the preserved tissue avoiding an aggressive decalcification of the annulus.
In conclusion, this technique is safe, reproducible and easy to perform without significant prolongation of clamping time and with satisfactory short and mid-term results. This fact has led us to a wider application of total chordal preservation during MVR.
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References
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- Talwar S, Jayanthkumar HV, Kumar AS. Chordal preservation during mitral valve replacement: basis, techniques and results. Ind J Thorac Cardiovasc Surg 2005;21:45-52.
- Chowdhury UK, Kumar AS, Airan B, Mittal D, Subramaniam KG, Prakash R, Seth S, Singh R, Venugopal P. Mitral valve replacement with and without chordal preservation in a rheumatic population: serial echocardiographic assessment of left ventricular size and function. Ann Thorac Surg 2005;79:1926-1933.[Abstract/Free Full Text]
- Thomson LE, Chen X, Greaves SC. Entrapment of mitral chordal apparatus causing early postoperative dysfunction of a St. Jude mitral prosthesis. J Am Soc Echocardiogr 2002;15:843-844.[CrossRef][Medline]
- Sintek CF, Pfeffer TA, Kchamba TA, Khonsari SR. Mitral valve replacement: technique to preserve the subvalvular apparatus. Ann Thorac Surg 1995;59:1027-1029.[Abstract/Free Full Text]
- Miki S, Kusuhara K, Ueda Y, Komeda M, Ohkita Y, Tahata T. Mitral valve replacement with preservation of chordae tendineae and papillary muscles. Ann Thorac Surg 1988;45:28-34.[Abstract]
- Kuralay E, Demirkilic U, Gunay C, Tatar H. Mitral valve replacement with bileaflet preservation: a modified technique. Eur J Cardiothorac Surg 2002;22:630-632.[Abstract/Free Full Text]
- Sasaki H, Ihashi K. Chordal-sparing mitral valve replacement: pitfalls and techniques to prevent complications. Eur J Cardiothorac Surg 2003;24:650-652.[Abstract/Free Full Text]
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Abstract
1. Introduction
