Mitral Valve Repair With Artificial Chordae: A Review of Its History, Technical Details, Long-Term Results, and Pathology

doi:10.1016/j.athoracsur.2011.09.015

The Annals of Thoracic Surgery

Volume 93, Issue 2, February 2012, Pages 684-691

https://doi.org/10.1016/j.athoracsur.2011.09.015 Get rights and content

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 Artificial chordae made of autologous or xenograft pericardium have been replaced by chordae made of expanded polytetrafluoroethylene (PTFE), a material with the unique property of becoming covered by host fibrosa and endothelium.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.

Section snippets

Material and Methods

A search of the Medline and PubMed databases was conducted for articles in the English language, supplemented by information obtained from archives of the journals available on the CTSNet website and from personal files. Pertinent articles were selected on the basis of the following keywords: mitral valve repair, mitral valvuloplasty, mitral chordae replacement, artificial chordae, expanded polytetrafluoroethylene sutures, and Gore-Tex sutures. Articles containing information on the use of

The Use of Pericardium

In patients with degenerative mitral valve disease, mitral incompetence is most often a consequence of the elongation or rupture of chordae tendineae, or both [9, 10]. Successful repair in this condition was occasionally achieved by direct suture of the affected chorda or leaflet to the papillary muscle, or by chordal replacement with various types of sutures (silk, nylon, mersilene, or other, unspecified materials) as shown by scattered case reports or small clinical series in the early or

Surgical Techniques

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, 37, 38]. In this technique, 4-0 to 6-0 sutures are usually used to construct as many chordae as considered necessary. In the original technique, ePTFE sutures were attached to a papillary muscle in a mattress fashion, with reinforcement by Teflon pledgets on both sides, and were then tied [32]. The

Long-Term Results

The results of mitral valve repair have been excellent for periods of up to 20 years both in terms of patient survival and the stability of repair [3, 4]. However, most reports of such repair in the literature present its results as cumulative data, without stratification according to the technique used, which prevents full evaluation of the effect of artificial chordae on the outcomes of such repair. David and associates reported their experience with mitral valve repair with and without

Pathology Associated With the Use of ePTFE Chordae

Because of the excellent long-term durability of mitral valve repair with ePTFE sutures, little is known about the structural changes observed in artificial chordae implanted in patients, although some information about this can be obtained from a few reports of clinical and pathologic findings. The early changes observed in ePTFE sutures are similar to those observed in animal experiments, indicating that artificial chordae made of ePTFE soon become covered by fibrous tissue, although with a

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Cited by (67)

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.
Repair of mitral regurgitation due to posterior leaflet prolapse. What has changed?
2023, Cirugia Cardiovascular
La reparación de la insuficiencia mitral por prolapso del velo posterior ha evolucionado en los últimos 20 años desde las técnicas clásicas de Carpentier hacia procedimientos menos agresivos con el tejido valvular. Nuestro objetivo es describir la evolución del tratamiento de esta patología en nuestro centro.
Estudio retrospectivo de pacientes con prolapso de velo posterior operados en nuestro centro desde 2001 a 2021. Recogida de datos intraoperatorios y datos ecocardiográficos y de seguimiento durante 20 años.
Se incluyeron 260 pacientes operados en dos períodos: hasta 2010, 84 pacientes (grupo A) y desde 2011, 176 pacientes (grupo B). Las técnicas más utilizadas en el grupo A fueron la resección cuadrangular (51 pacientes, 60,7%), la triangular (20 pacientes, 23,8%) y la implantación de neocuerdas (8 pacientes, 9,5%) siendo la tasa de reparabilidad del 98,8%, y en el grupo B fueron la resección triangular (86 pacientes, 48,9%), la implantación de neocuerdas (45 pacientes, 25,6%) y la resección cuadrangular (28 pacientes, 15,9%) con una reparabilidad del 96,6%. La mortalidad hospitalaria fue del 3,6% (n = 3) en el grupo A y del 0,6% (n = 1) en el B. Supervivencia actuarial 50% a los 20 años (A) y 81% a los 10 años (B). Tasa libre de reintervención del 98% (A) y del 97,2% (B). Teniendo en cuenta las técnicas más frecuentemente utilizadas, la recidiva de insuficiencia mitral ≥ II fue mayor en los pacientes con neocuerdas (n = 14, 26,4%) que en los casos de resección cuadrangular (n = 10, 13,2%) o triangular (n = 13, 12,4%).
Nuestro centro ha evolucionado hacia técnicas con menor resección tisular y mayor utilización de neocuerdas, aunque ambas técnicas han mostrado excelentes resultados a largo plazo. Las técnicas resectivas son más reproducibles y duraderas que la implantación de neocuerdas.
Repair of mitral regurgitation due to posterior leaflet prolapse has evolved in the last 20 years from the classic Carpentier techniques towards less aggressive procedures with the valve tissue. The objective of this study is to describe the evolution of our center in the treatment of this pathology.
Retrospective study of 260 patients with posterior leaflet prolapse operated on our center since 2001, including them into two groups: A (until 2010) and B (since 2011). We collected intraoperative data and echocardiographic and follow-up data for 20 years.
260 patients operated on in two periods were included: until 2010, 84 patients (group A) and since 2011, 176 patients (group B). The most commonly used techniques in group A were quadrangular resection (51 patients, 60.7%), triangular resection (20 patients, 23.8%), and neochordal implantation (8 patients, 9.5%), with a reparability rate of 98.8% and in group B, triangular resection (86 patients, 48.9%), neochordal implantation (45 patients, 25.6%) and quadrangular resection (28 patients, 15.9%) with a reparability rate of 96.6%. Hospital mortality was 3.6% (n = 3) in group A and 0.6% (n = 1) in group B. Actuarial survival was 50% at 20 years (A) and 81% at 10 years (B). Reoperation-free rate was 98% (A) and 97.2% (B). Taking into account the most frequently used techniques, the recurrence of mitral regurgitation ≥ II was greater in patients with neochordae (n = 14, 26.4%) than in cases with quadrangular (n = 10, 13.2%) or triangular resection (n = 13, 12.4%).
Our center has evolved towards techniques with less tissue resection and greater use of neochordae although both techniques have showed excellent long-term results. Resective techniques are more reproducible and durable than neochordal implantation.
Mitral valve repair in anterior leaflet prolapse: techniques, indications and results
2023, Cirugia Cardiovascular
La reparación quirúrgica de la insuficiencia mitral por prolapso de uno o varios segmentos del velo anterior, tanto aislada como en combinación con patología comisural o de velo posterior, es compleja. Las técnicas resectivas presentan menos indicaciones y peores resultados que en el prolapso del velo posterior (PrVP). Las técnicas de preservación son la transposición o acortamiento de cuerdas o de músculos papilares, la reparación borde-con-borde o, más frecuentemente, la implantación de neocuerdas. En este trabajo se pretenden revisar las diferentes variantes técnicas para el abordaje del prolapso del velo anterior mitral, que en el caso de la implantación de neocuerdas son tremendamente variadas, junto a sus indicaciones y resultados.
Surgical mitral valve repair due to anterior leaflet prolapse is complex, both isolated or combined with commisural and/or posterior leaflet pathology. Resective techniques are less indicated and are associated with worse long-term results that those observed after posterior leaflet resection. Leaflet preservation techniques are pappilary muscle or chordae transposition or shortening, the edge-to-edge repair and, more frequently, artificial neochordae implantation. This paper aims to describe the most important techniques used for anterior leaflet prolapse repair, extremely numerous in the neochordae implantation subset, in addition to their indications and results.
Mitral Repair With Complete Rings or Posterior Bands in Barlow Disease: Long-term Results
2023, Annals of Thoracic Surgery
Complete rings or posterior bands are both commonly used during mitral valve repair, but which one ensures the best long-term outcome in patients with Barlow disease is a topic of debate. This study evaluated whether the type of annuloplasty device affects the long-term durability of the repair.
We selected 296 consecutive patients with severe mitral regurgitation due to Barlow disease who underwent edge-to-edge mitral repair at our institution between 2004 and 2013. For the edge-to-edge repair, a complete semirigid ring was used in 151 patients, whereas a posterior flexible band was used in 145 patients. The clinical and echocardiographic outcomes of both groups were compared at long-term follow-up.
At 14 years, the overall survival was 87.3% ± 2.79% in the ring group and 94.1% ± 2.30% in the band group (P = .056). The incidence of mitral valve reintervention was 4.9% ± 1.95% in the ring group and 5.5% ± 2.53% in the band group (P = .371) at 14 years. The incidence of recurrence of mitral regurgitation ≥3+ and ≥2+ was 8.3% ± 2.64% in the ring group and 8.7% ± 3.07% in the band group (P = .991) and 26.5% ± 4.23% in the ring group and 17.4% ± 3.26% in the band group (P = .697), respectively. Mitral regurgitation ≥1+ at discharge was the only independent predictor of reoperation and recurrence of mitral regurgitation ≥3+ in the long-term.
In patients with Barlow disease undergoing edge-to-edge mitral valve repair, the type of annuloplasty device does not influence the long-term results. Achieving an optimal immediate result remains the key to maintain the stability of the repair at long-term.
Beyond the 10-Year Horizon: Mitral Valve Repair Solely With Chordal Replacement and Annuloplasty
2023, Annals of Thoracic Surgery
The long-term outcomes of mitral valve repair by nonresection techniques, such as annuloplasty and chordal replacement, for degenerative mitral valve regurgitation were investigated.
All consecutive patients with degenerative mitral regurgitation who received solely chordal replacement and annuloplasty for mitral valve repair between 2003 and 2010 at the German Heart Center Munich were reviewed. The endpoints of this retrospective study were survival, cumulative incidence of reoperation on the mitral valve, and cumulative incidence of significant recurrent mitral regurgitation.
A total of 346 patients were evaluated. The median follow-up period was 10.86 (range, 0.01-15.86) years. The 30-day mortality rate was 0.58% (n = 2 of 346), whereas the 5-year survival was 92.97% ± 1.41%. At 5 years, cumulative incidence of recurrent mitral regurgitation was 6.87% ± 1.57% and cumulative incidence of reoperation on the mitral valve was 3.69% ± 1.05%. Survival at 10 years was 83.35% ± 2.15%. At 10 years, cumulative incidence of recurrent mitral regurgitation was 13.31% ± 2.22% and cumulative incidence of reoperation was 7.84% ± 1.55%. Cox regression analysis identified age, diabetes mellitus, and reduced left ventricular ejection fraction <55% as independent risk factors for death. Left ventricular ejection fraction <55% was revealed as independent risk factor for significant recurrent mitral regurgitation.
This study demonstrated excellent long-term outcomes with low incidence of reoperation after mitral valve repair using chordal replacement in a highly selected patient cohort. Our findings emphasized the importance of early intervention in severe degenerative mitral regurgitation, especially in patients with reduced left ventricular ejection fraction.
Pathological mitral valve repair: a multidisciplinary adventure over the past 100 years
2022, Cirugia Cardiovascular

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ReviewMitral Valve Repair With Artificial Chordae: A Review of Its History, Technical Details, Long-Term Results, and Pathology

Section snippets

Material and Methods

The Use of Pericardium

Surgical Techniques

Long-Term Results

Pathology Associated With the Use of ePTFE Chordae

J Am Coll Cardiol

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

Int J Cardiol

J Thorac Cardiovasc Surg

Ann Thorac Surg

Dis Chest

J Thorac Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

Ann Thorac Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

Ann Thorac Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

Ann Thorac Surg

J Thorac Cardiovasc Surg

Cardiovasc Pathol

J Thorac Cardiovasc Surg

Ann Thorac Surg

J Thorac Cardiovasc Surg

Valve repair versus valve replacement for degenerative mitral valve disease

J Thorac Cardiovasc Surg

Review
Mitral Valve Repair With Artificial Chordae: A Review of Its History, Technical Details, Long-Term Results, and Pathology