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Letters to the Editor |
Department of Cardiovascular Surgery, Suleyman Demirel University Medical School, Isparta, Turkey
Received 11 July 2007; accepted 6 August 2007.
* Corresponding author. Address: Turan Mh 126, Cd Okur Sitesi No: 22/1, 32040 Isparta, Turkey. Tel.: +90 246 2236968; fax: +90 246 2326280. (Email: kirisilker{at}yahoo.com).
Key Words: Chordal preservation • Leaflet transposition • Mitral valve replacement
We read with interest the article entitled ‘Posterior transposition of anterior leaflet for complete chordal preservation’ by Fuster et al. [1]. The described technique is slightly different from other chordal preservation techniques. We congratulate them on their excellent results.
According to the described technique, the incision is carried out to both commissure and the leaflet is widely mobilized. Then it is reimplanted as a large patch under the posterior leaflet with three or four U stitches and its basal portion without chordae is trimmed to remove excess tissue. The remnant with all the chordae is resuspended and plicated on the mitral annulus. Fuster et al. [1] has used this technique in rheumatic pathology with bioprosthesis and bileaflet mechanical prostheses. It has been proposed by the authors that this technique solves the two primary problems generally encountered with chordal preservation during mitral valve replacement: interference with the prosthesis and left ventricular obstruction [1].
However, we think that the primary concern of the chordal preservation technique is to improve or at least maintain left ventricular functions in the postoperative period. Therefore, we have some concerns about the postoperative left ventricular performance after this technique. Would Fuster et al. tell us about left ventricular functions of the patients who underwent mitral valve replacement using this technique? Did they evaluate the effect of this technique on cardiac performance in the postoperative early- or mid-term by comparing with a control group that underwent another chordal preservation technique? The technique by Fuster et al. [1] resembles the technique by Feikes et al. [2] which was described in 1990. Furthermore, Moon et al. [3] reported that the left ventricle pressure–volume relationship did not differ between the techniques by Feikes et al. [2] and Khonsali and Sintek [4]. The function of papillary muscles may be preserved in both techniques. However, we think that anterior regional wall motion does not necessarily improve with posterior transposition of anterior leaflet because the movement of posterior wall may be excessively strengthened by the preserved chordae. Anterior chordal sparing techniques such as reported by Khonsali and Sintek [4] and Kuralay et al. [5] may maintain adequate global and regional cardiac function after mitral valve replacement. Several modifications can also be done for reducing left ventricular outflow tract obstruction in these techniques. But the main thing in both leaflet preservation is reattaching the chordae in the natural position to improve left ventricular performance. The author claimed that the techniques described by Khonsali are time consuming and require prolonged clamping time. We do not agree with him. Every effort should be made to increase left ventricular performance and reattach the chordae into the natural position during the leaflet preserving mitral valve replacement. We are also not sure whether the technique by Fuster et al. [1] increases left ventricular performance more than other natural position reattachment techniques do.
In fibrotic leaflet tissue conditions such as rheumatic pathology, the technique described by Fuster et al. [1] allows implantation of a prosthesis in a larger size. We also agree that the technique eliminates left ventricular outflow obstruction.
References
This article has been cited by other articles:
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  R. G. Fuster, I. Rodriguez, V. Estevez, and A. Vazquez Reply to kiris et Al. Eur. J. Cardiothorac. Surg., November 1, 2007; 32(5): 821 - 822. [Full Text] [PDF]
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