Pre-Measured Artificial Chordae for Mitral Valve Repair

doi:10.1016/j.athoracsur.2007.04.046

The Annals of Thoracic Surgery

Volume 84, Issue 6, December 2007, Pages 2127-2129

https://doi.org/10.1016/j.athoracsur.2007.04.046 Get rights and content

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.

Section snippets

Valve Inspection

After review of the intraoperative transesophageal echocardiogram and surgical exposure, systematic inspection of all valve components was performed. The prolapsing segment and elongated or ruptured chordae were identified. Stay sutures were placed around normal chords on either side of the prolapsing segment; the segment of leaflet between these sutures was the region that required chordal support. Next, the papillary muscles were inspected to identify the site for chordal attachment.

Comment

A variety of techniques are available to correct anterior leaflet prolapse. Although the creation of artificial chordae was described more than 2 decades ago, it has recently increased in popularity. The innovation by Von Oppell and Mohr [1] and the recent development of a commercially available caliper to facilitate the use of pre-measured chordae (Estech, San Ramon, CA) considerably simplifies the procedure. As with Von Oppell and Mohr [1], we find this technique to be both reliable and

References (4)

U.O. Von Oppell et al.
Chordal replacement for both minimally invasive and conventional mitral valve surgery using premeasured Gore-Tex loops
Ann Thorac Surg
(2000)
T.E. David
Artificial chordae
Sem Thorac Cardiovasc Surg
(2004)

There are more references available in the full text version of this article.

Cited by (33)

Anatomical Mitral Valve Repair: Mathematical Prediction of Artificial Chordae Length in Para-Commissural Regions
2024, Current Problems in Cardiology
To develop a mathematical formula for calculating the length of ruptured mitral valve chordae (with a view to surgically replacing them with artificial chordae) when rupture occurs at scallop A1, A3, P1, or P3. We studied human cadaver hearts collected by the Faculty of Medicine at Amiens Picardy University Hospital. The donors’ mean age standard deviation age at death was 79 ± 10. After weighing and dissection, we counted the number of para-commissural chordae per scallop and measured their length with a digital calliper. A total of 31 human cadaver hearts (14 from females and 17 from males) were analyzed. The mean lengths of scallops A1, A2, A3, P1, P2, and P3 were 17.45, 19.42, 17.58, 13.32, 14.52, and 13.26 mm, respectively. A linear regression gave the following mathematical equations: A1 = 0.96 × A2- - 1.3 (R: 0.99; P < 0.001); A3 = 0.9 × A2 + 0.17 (R: 0.95; P < 0.01); P1 = 0.87 × P2 +0.74 (R: 0.89; P < 0.001), and P3 = 0.91 × P2 - 0.01 (R: 0.87; P < 0.0001). When the patient's anatomy prevents manual measurements of the chordae during mitral valve repair surgery, the mathematical formulae derived here can be used to predict the length of the chordae on A1, A3, P1, and P3 from the length of the chordae on A2 and P2. The mitral chordae can therefore be replaced with prostheses with a great degree of precision.
Simple versus complex degenerative mitral valve disease
2018, Journal of Thoracic and Cardiovascular Surgery
Citation Excerpt :
Historically, repair of an anterior leaflet has been more challenging than posterior leaflet repair and has been accompanied by reduced durability.5,23-25 Anterior repair techniques have evolved from chordal shortening and chordal transfer to insertion of polytetrafluoroethylene chordae.5,26-28 Creation of artificial chordae has been associated with excellent durability and is amenable to less invasive approaches, making it our preferred technique in recent years.
At a center where surgeons favor mitral valve (MV) repair for all subsets of leaflet prolapse, we compared results of patients undergoing repair for simple versus complex degenerative MV disease.
From January 1985 to January 2016, 6153 patients underwent primary isolated MV repair for degenerative disease, 3101 patients underwent primary isolated MV repair for simple disease (posterior prolapse), and 3052 patients underwent primary isolated MV repair for complex disease (anterior or bileaflet prolapse), based on preoperative echocardiographic images. Logistic regression analysis was used to generate propensity scores for risk-adjusted comparisons (n = 2065 matched pairs). Durability was assessed by longitudinal recurrence of mitral regurgitation and reoperation.
Compared with patients with simple disease, those undergoing repair of complex pathology were more likely to be younger and female (both P values < .0001) but with similar symptoms (P = .3). The most common repair technique was ring/band annuloplasty (3055/99% simple vs 3000/98% complex; P = .5), followed by leaflet resection (2802/90% simple vs 2249/74% complex; P < .0001). Among propensity-matched patients, recurrence of severe mitral regurgitation 10 years after repair was 6.2% for simple pathology versus 11% for complex pathology (P = .007), reoperation at 18 years was 6.3% for simple pathology versus 11% for complex pathology, and 20-year survival was 62% for simple pathology versus 61% for complex pathology (P = .6).
Early surgical intervention has become more common in patients with degenerative MV disease, regardless of valve prolapse complexity or symptom status. Valve repair was associated with similarly low operative risk and time-related survival but less durability in complex disease. Lifelong annual echocardiographic surveillance after MV repair is recommended, particularly in patients with complex disease.
Premeasured Chordal Loops for Mitral Valve Repair
2016, Annals of Thoracic Surgery
Premeasured expanded polytetrafluoroethylene chordal loops with integrated sutures for attachment to the papillary muscle and leaflet edges facilitate correction of mitral valve prolapse. Configured as a group of 3 loops (length range 12 to 24 mm), the loops are attached to a pledget that is passed through the papillary muscle and tied. Each of the loops has 2 sutures with attached needles; these needles are passed through the free edge of the leaflet and then the sutures are tied to each other, securing the chordal loop to the leaflet.
Mitral valve repair with artificial chordae: A review of its history, technical details, long-term results, and pathology
2012, Annals of Thoracic Surgery
Citation Excerpt :
Each two-armed Gore-Tex suture allows the creation of a pair of neochordae. Recently, techniques have been proposed by which multiple chordae can be obtained by using premeasured Gore-Tex loops [36–38]. In this technique, 4-0 to 6-0 sutures are usually used to construct as many chordae as considered necessary.
Mitral valve repair is considered the procedure of choice for correcting mitral regurgitation in myxomatous disease, providing long-term results that are superior to those with valve replacement. The use of artificial chordae to replace elongated or ruptured chordae responsible for mitral valve prolapse and severe mitral regurgitation has been the subject of extensive experimental work to define feasibility, reproducibility, and effectiveness of this procedure. Artificial chordae made of autologous or xenograft pericardium have been replaced by chordae made of expanded polytetrafluoroethylene (PTFE), a material with the unique property of becoming covered by host fibrosa and endothelium. The use of artificial chordae made of PTFE has been validated clinically over the past 2 decades and has been an increasing component of the surgical armamentarium for mitral valve repair. This article reviews the history, details of the relevant surgical techniques, long-term results, and fate of artificial chordae in mitral reconstructive surgery.
Is an anterior mitral leaflet prolapse still a challenge?
2010, Archives of Cardiovascular Diseases
Quadrangular resection is the gold standard in the treatment of posterior leaflet prolapse. Anterior leaflet prolapse has been considered a more challenging problem; several techniques are available to treat it, all with the same goal – mitral valve competency. Nowadays, good long-term results are reported, similar to those for posterior leaflet prolapse. Certain improvements may explain these results, especially improvements in transesophageal echocardiography (including three-dimensional echocardiography), which allow the detection of atypical mitral regurgitation and its mechanism.
La résection quadrangulaire est le traitement de choix du prolapsus mitral postérieur. Le prolapsus antérieur a toujours été considéré comme un challenge chirurgical, plusieurs techniques chirurgicales sont disponibles pour le corriger et pour atteindre le même but : la compétence de la valve. Désormais de bons résultats à long terme sont décrits, comparables à ceux obtenus après correction d’un prolapsus postérieur. Plusieurs progrès et innovations peuvent expliquer ces résultats, en particulier, ceux de l’ETO (comprenant l’échographie 3D) qui localisent précisément les fuites mitrales difficiles et précisent leurs mécanismes.
Accessory left atrial chordae: An unusual cause of mitral valve insufficiency
2010, Journal of Thoracic and Cardiovascular Surgery
Citation Excerpt :
The abnormal chordae was resected flush with the atrial wall and the edge of the leaflet, and the central cleft was closed with simple sutures. The normal chordae were measured, and polytetrafluorethylene (Gore-Tex 4-loop neochordal structures; W. L. Gore & Associates, Inc, Newark, Del) 4-loop neochordal structures were attached between the free edge of the anterior leaflet and the base of the posteromedial papillary muscle using our previously described technique.1 The valvuloplasty was reinforced with a posterior ring annuloplasty using a 28-mm Cosgrove–Edwards band.

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How to do itPre-Measured Artificial Chordae for Mitral Valve Repair

Section snippets

Valve Inspection

Comment

Ann Thorac Surg

Sem Thorac Cardiovasc Surg

How to do it
Pre-Measured Artificial Chordae for Mitral Valve Repair