Asian Cardiovasc Thorac Ann 1998;6:49-51
© 1998 Asia Publishing EXchange Pte Ltd
Chordal Replacement with Expanded Polytetrafluoroethylene Suture: Early Results
Taweesak Chotivatanapong, MD,
Pradistchai Chaiseri, MD,
Choosak Kasemsarn, MD,
Vibhan Sungkahapong, MD
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Cardiothoracic Surgical Division Central Chest Hospital Nonthaburi, Thailand
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For reprint information contact: Taweesak Chotivatanapong, MD Cardiothoracic Surgical Division Central Chest Hospital Tivanonth Road Nonthaburi 11000, Thailand Tel:66 2 588 3119 Fax:66 2 591 8071 or 588 3115
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ABSTRACT
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Expanded polytetrafluoroethylene suture has been used for chordal replacement to achieve better results of mitral valve repair in patients with severe subvalvular disease. From March 1994 to December 1996, 16 patients with mitral valve disease were successfully repaired with this suture at Central Chest Hospital. There were 10 males and 6 females. The average age was 36.5 years. Mean follow-up was 18.18 months. Mitral valve disease was rheumatic in origin in most patients. The suture was attached to the posterior leaflet in 11 patients and to the anterior leaflet in the other 5. The average number of pairs of sutures used per patient was 1.37 (range 1 to 4 pairs). The average number of surgical procedures for mitral valve repair per patient was 5.1. There was no hospital mortality and no thromboembolic complication or reoperation during this study. Postoperative functional status and mitral regurgitation improved substantially. We concluded from this study that this suture can be used safely and effectively for chordal replacement in mitral valve repair.
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INTRODUCTION
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Severe disease of the subvalvular apparatus of mitral valve (MV) often precludes successful MV repair. Expanded polytetrafluoroethylene (PTFE) suture was introduced for chordal replacement in order to achieve a better result. In this study, we reviewed our early experience using PTFE suture for chordal replacement in patients with severe submitral valvular disease.
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MATERIALS AND METHODS
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Between March 1994 and December 1996, 381 patients underwent MV surgery at Central Chest Hospital. MV repair was successful in 122 patients. PTFE sutures were used in 16 cases and formed the basis of this study. There were 10 males and 6 females between 17 and 56 years of age with a mean age of 36.5 years. Follow-up ranged from 4 to 34 months with an average of 18.18 months. In the majority of cases (n = 10), mitral valve lesions were caused by rheumatic disease. The other causes were endocarditis in 4 patients, degenerative disease in 1, and tear of the anterior mitral leaflet after balloon mitral valvuloplasty in 1 case. Eight patients had isolated mitral valve lesions; 5 had mitral regurgitation (MR), 2 had mitral stenosis (MS) and the other patient had both MR and MS. The other 8 patients had combined valvular lesions: 3 had aortic regurgitation (AR) and MR; 2 had MS, MR, AR, and tricuspid regurgitation (TR); 1 had MS, MR, and TR; 1 had MS, AR, and TR; and the other patient had MS, MR, TR, AR, and aortic stenosis.
Preoperatively, 3 patients were in New York Heart Association functional class IV, 12 were in class III, and the other one was in class II. Preoperative echocardiography in 13 patients with significant mitral regurgitation showed 6 had +4 degrees, 4 had +3 degrees, and 3 had +2 degrees. Three of the patients had mitral stenosis with mitral valve areas of 0.5, 0.97, and 0.59 cm2, respectively. The average mitral valve area was 0.68 cm2. Details of the operative findings are listed in Table 1
. It should be noted that some patients had more than one cause of mitral regurgitation. All patients were operated on by the same surgeon and completely followed up by the same surgical team.
OPERATIONS AND SURGICAL TECHNIQUES
A median sternotomy was performed in all patients and cardiopulmonary bypass was instituted with moderate hypothermia (28° to 30°C) and cold blood cardioplegia. Warm terminal blood reperfusion was given prior to aortic de-clamping. The mitral valve was approached by the combined superior-transseptal incision advocated by Guiraudon and colleagues.1 The mitral valve was thoroughly assessed and appropriate MV repair procedures were used accordingly. The PTFE suture, usually 5/0 double-arm Gore-Tex suture (WL Gore, Flagstaff, AZ, USA) was first placed at the fibrous part of the papillary muscle and tied without pledgets. It was then brought to the rim of mitral leaflet from the ventricular side to the atrial side. The optimal length of the new chordae was achieved by comparison to a point of reference, usually the anterolateral scallop of the posterior leaflet. Two Liga clips were placed at both arms of the suture at the atrial side of the leaflet to prevent any displacement. The suture was tied over the Liga clips and then brought down to the ventricular side of the leaflet and tied. The Liga clips were removed when the procedure was completed. The valve was tested for competency by flushing the left ventricle with normal saline solution (0.9% w/v). The incision was closed with 4/0 Prolene (Ethicon Ltd., Edinburgh, UK).1
Isolated MV repairs were carried out in 8 patients. The other 8 patients had concomitant procedures: 3 had combined MV repair and aortic valve replacement (AVR); 2 had MV and aortic valve repair as well as De Vega's tricuspid valve annuloplasty (TVA); 1 had MV repair and TVA; 1 had MV repair, AVR, and TVA; and 1 had both mitral and aortic valve repair. All patients required multiple procedures to accomplish mitral valve repair. The average MV repair procedures per patient in this study was 5.1. PTFE sutures were used for chordal replacement of the posterior leaflet in 11 patients and of the anterior leaflet in 5 patients. The average number of pairs of PTFE sutures used per patient in this series was 1.37 (range from 1 to 4 pairs). Prosthetic rings were used in the majority of cases (Carpentier-Edwards Classic; Baxter-Edwards A.G., Horw, Switzerland). Details of the surgical procedures for MV repair are listed in Table 2. Anticoagulants were given to these patients for 12 weeks postoperatively. The average bypass and aortic cross-clamp times were 2 hours 48 minutes and 2 hours 9 minutes, respectively.
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RESULTS
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There was no hospital mortality in this study. Neither thromboembolic complication nor reoperation occurred during this period. Postoperatively, the patients' functional status improved substantially. Ten patients were in New York Heart Association functional class I and 6 were in class II. Postoperative echocardiography also revealed an improvement in those patients with significant mitral regurgitation before the operation. Seven had no mitral regurgitation postoperatively, 4 had +1 degree, and the other 2 had +2 degrees. The 3 patients with pure mitral stenosis showed improvement in their mitral valve area from an average of 0.68 cm2 before the operation to 2.32 cm2 after the surgery. Two of them had trivial mitral regurgitation and the other had none. One patient died 20 months postoperatively from pneumonitis that aggravated her chronic obstructive pulmonary disease.
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DISCUSSION
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Mitral valve repair has become the preferred operation for MV disease because of several advantages over MV replacement.2,3 However, severe disease of the subvalvular apparatus is often the major factor that precludes successful valve repair. Although several procedures have been developed to overcome this problem, results are variable and there is still a major challenge for the cardiac surgeon in the situation where no appropriate native chordae is available.2–5 PTFE sutures have been used as artificial chordae with good results in both animal and clinical studies. Examinations in both animal and human hearts revealed that the PTFE suture retained its pliability and flexibility. Microscopically, the suture was covered with a layer of endothelial cells and a thin collagen and fibrin coating.6–8 This may account for its durability and anticoagulant property. PTFE sutures were useful in our patients because most of them had severe subvalvular lesions caused by rheumatic disease, in which it is often found that there are no appropriate native chordae for the repair. PTFE sutures allowed successful MV repair in these patients who would otherwise have had to undergo MV replacement.
The technique for achieving the optimal length of the new chordae is very important in order to obtain a good result. Several effective techniques have been described.9,10 The technique used in this study has proved to be easy and reproducible for us. The use of autologous glutaraldehyde-treated pericardium to reconstruct the mitral leaflet in combination with PTFE sutures was successful in 4 patients with complications from bacterial endocarditis. Prosthetic ring implantation was carried out in the majority of cases to increase the coaptation and reduce the tension on the PTFE suture.
Our findings show that using PTFE suture for chordal replacement gave good early results in 16 of our patients. It proved to be especially useful in circumstances of severe subvalvular disease. This technique further expands our ability to repair diseased mitral valves.
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REFERENCES
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This article has been cited by other articles:
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T. Chotivatanapong, P. Chaiseri, C. Kasemsarn, C. Yosthasurodom, and V. Sungkahapong
Chordal Replacement With Polytetrafluoroethylene Suture: Midterm Results
Asian Cardiovasc Thorac Ann,
June 1, 2001;
9(2):
90 - 92.
[Abstract]
[Full Text]
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ABSTRACT
INTRODUCTION
