Asian Cardiovasc Thorac Ann 2007;15:531-533
© 2007 Asia Publishing EXchange Ltd
Chordal Replacement with Temporary Alfieri Stitch for Anterior Leaflet Prolapse
Hironobu Morimoto, MD,
Koji Tsuchiya, MD,
Masato Nakajima, MD,
Yoshitaka Mitsumori, MD,
Kaori Kato, MD
Department of Cardiovascular Surgery, Yamanashi Central Hospital Yamanashi, Japan
For reprint information contact: Hironobu Morimoto, MD, Tel: 81 3 3353 8111, Fax: 81 3 3356 0441, Email: hironobu12jp{at}yahoo.co.jp, Department of Cardiovascular Surgery, The Heart Institute of Japan, Tokyo Women’s Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo 162-8666, Japan.
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ABSTRACT
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In mitral valve regurgitation due to anterior leaflet prolapse and other complicated lesions, chordal replacement with expanded polytetrafluoroethylene is widely practiced. The most troublesome aspects of this procedure are the determination of the necessary length of the artificial chorda and the tying of the knot. We describe a simple technique for artificial chordal replacement using an Alfieri stitch, that has been successfully applied to 10 patients with anterior leaflet prolapse.
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INTRODUCTION
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Artificial chordal replacement with expanded polytetrafluoroethylene has become the surgical treatment of choice for mitral valve regurgitation due to anterior leaflet prolapse and other complicated lesions. However, the success of this procedure depends on the achievement of correct artificial chordal length, which in turn introduces two technical difficulties: the determination of the target length itself and the tying of the knot. We describe 10 cases involving a simple technique for artificial chordal replacement using the double orifice technique (Alfieri stitch)1 for mitral valve regurgitation due to anterior leaflet prolapse.
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PATIENTS AND METHODS
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Between June 1999 and August 2005, we performed mitral valve repair on 10 patients with mitral regurgitation due to anterior leaflet prolapse, at Yamanashi Central Hospital. The group comprised 6 men and 4 women. Patient age ranged from 18 to 75 years (mean ± SD: 51.7 ± 17.8 years). Preoperatively, 4 patients were in New York Heart Association (NYHA) functional class II and 6 were in class III. Preoperative echocardiography showed that the degree of mitral regurgitation was moderate to severe in all patients. There were 8 patients with degenerative disease and 2 with infective endocarditis (Table 1
). We implanted an average of 2.6 artificial chordae per patient (range: 1–4).
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TECHNIQUE
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After cardiopulmonary bypass was established, moderate systemic hypothermia was employed. Under ventricular fibrillation, the left atrium was incised on the posterior interatrial groove, extending posteriorly beneath both caval veins. An analysis of the mitral valve was performed that included determination of the site of leaflet prolapse, the extent of annular dilatation, and the site of the jet lesion. After antegrade cold blood cardioplegia was administered (with topical hypothermia) and cardiac arrest was obtained, the mitral valve was repaired. The operative technique for artificial chordal replacement was performed by passing one or more 5–0 polytetrafluoroethylene (Gore-Tex; WL Gore & Assoc, Flagstaff, AZ, USA) sutures into the head of the papillary muscle. The two arms of the sutures were passed through the leaflet free edge at the prolapse site, from the ventricular side to the atrial side. Next, a double orifice mitral valve was created by approximating the free edges of the leaflets at the site of regurgitation using a temporary 5–0 polypropylene suture (the Alfieri stitch) as a guide for determining the length of the artificial chordae (Figure 1). The prolapsed leaflet site was resuspended by suturing the free edge of the prolapsed leaflet to the corresponding edge of the opposing leaflet. During injection of saline solution into the ventricle, the symmetry of leaflet apposition–the degree of which limits the incompetence of the mitral valve–was evaluated, and the proper length for the artificial chordae was established. This length was fixed using a nerve hook, and the Gore-Tex stitches were then tied without slippage of the knot. Finally, the temporary Alfieri stitch was removed and rigid ring annuloplasty (Carpentier-Edwards annuloplasty ring, Edwards Lifesciences, Irvine, CA, USA) was performed.
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Figure 1. Chordal replacement with temporary Alfieri stitch. (A) Prolapsing anterior leaflet due to chordal rupture, (B) A double orifice was created using a temporary suture. During injection of saline solution, symmetric leaflet apposition determined the proper length of the artificial chorda.
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RESULTS
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Operation time, cardiopulmonary bypass time, and aortic cross clamping time were 220 ± 40, 105 ± 18, and 68.4 ± 16 minutes, respectively. Intraoperative transesophageal echocardiography showed none or trivial mitral regurgitation after repair, in all cases. Echocardiography at hospital discharge demonstrated none or trivial mitral regurgitation in 8 cases and mild regurgitation in 2. There was no hospital death and all patients were discharged without complications. The mean follow-up period was 35.3 months (range: 1 to 78 months). At the end of the follow-up period, echocardiography showed no further changes in mitral regurgitation. There were no late deaths or thromboembolic events after the operation. No valve re-operations were required during the follow-up period. NYHA functional classification improved to I or II in all patients.
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DISCUSSION
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Mitral valve repair for anterior leaflet prolapse is not a simple cardiac surgical procedure. Nevertheless, repair using artificial chordae is well established. The efficacy of chordal replacement with Gore-Tex has been confirmed by its long-term durability and by the minimal risks of failure and re-operation.2,3
Various techniques4,5 have been reported for assisting the cardiac surgeon to determine the proper replacement chordal length. Our method, which uses a temporary Alfieri stitch, was employed in cases with only anterior leaflet prolapse. Here, the free edge of the prolapsing anterior leaflet was temporarily sutured to the opposing free edge of the normal posterior leaflet. With the left ventricle pressurized by saline solution, we resuspended the prolapsing anterior leaflet so as to yield artificial chordae of the proper length.
When degenerative changes give rise to anterior leaflet prolapse, we transfer a strong secondary chorda or a segment from the posterior leaflet, based on a repair strategy of using autologous tissue where possible. Conversely, in cases without strong chordae, we perform artificial chordal replacement. We regard our method to be simple and effective, and have achieved good results.
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ACKNOWLEDGMENTS
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The authors are grateful to Dr. Fuminaga Suetsugu for the fine illustration.
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REFERENCES
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- Alfieri O, Maisano F, De Bonis M, Stefano PL, Torracca L, Oppizzi M, et al. The double-orifice technique in mitral valve repair: a simple solution for complex problems. J Thorac Cardiovasc Surg 2001;122:674–81.[Abstract/Free Full Text]
- Kobayashi J, Sasako Y, Bando K, Minatoya K, Niwaya K, Kitamura S. Ten-year experience of chordal replacement with expanded polytetrafluoroethylene in mitral valve repair. Circulation 2000;102(19 Suppl 3):III30–4.[Medline]
- David TE, Armstrong S, Sun Z. Replacement of chordae tendineae with Gore-Tex sutures: a ten-year experience. J Heart Valve Dis 1996;5:352–5.[Medline]
- Von Oppell UO, Mohr FW. Chordal replacement for both minimally invasive and conventional mitral valve surgery using premeasured Gore-Tex loops. Ann Thorac Surg 2000;70:2166–8.[Abstract/Free Full Text]
- Kasegawa H, Kamata S, Hirata S, Kobayashi N, Mannouji E, Ida T, et al. Simple method for determining proper length of artificial chordae in mitral valve repair. Ann Thorac Surg 1994;57:237–9.[Abstract]
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