Asian Cardiovasc Thorac Ann 2001;9:90-92
© 2001 Asia Publishing EXchange Pte Ltd
Chordal Replacement With Polytetrafluoroethylene Suture: Midterm Results
Taweesak Chotivatanapong, MD,
Pradistchai Chaiseri, MD,
Choosak Kasemsarn, MD,
Chaiwuth Yosthasurodom, MD,
Vibhan Sungkahapong, MD1,
Cardiothoracic Surgical Division
1 Division of Anesthesia
Central Chest Hospital
Nonthaburi, Thailand
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For reprint information contact: Taweesak Chotivatanapong, MD Tel: 66 2 588 3119 Fax: 66 2 589 9321 email: taweesak13{at}hotmail.com Cardiothoracic Surgical Division, Central Chest Hospital, Tivanonth Road, Nonthaburi 11000, Thailand.
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Abstract
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From March 1994 to December 1999, polytetrafluoroethylene suture was used for chordal replacement during mitral valve repair in 30 patients. Follow-up ranged from 4 to 70 months with a mean of 36.6 months and was complete in 29 patients: 14 males and 15 females with a mean age of 40.6 years. Most (17) had rheumatic heart disease, 5 had degenerative disease, 6 had infective endocarditis, and 1 had ischemic heart disease. Preoperatively, 26 patients were in functional class III and IV. Operations comprised isolated mitral valve repair (15), combined mitral and tricuspid valve repair (4), mitral valve repair and aortic valve replacement (3), and others (7). The most frequent additional procedures were commissurotomy, papillotomy, resection of primary or secondary chordae, and chordal splitting. The mean cardiopulmonary bypass and aortic crossclamp times were 155.3 and 120.5 minutes, respectively. There was no hospital mortality. One patient died 20 months postoperatively from chronic obstructive lung disease. All survivors were in functional class I and II. Mitral regurgitation was reduced from a preoperative mean of +3.1 degrees to +0.43 degrees. No thromboembolic event or valve failure occurred during follow-up. It was concluded that polytetrafluoroethylene suture was safe and effective for mitral valve repair.
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Introduction
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Mitral valve (MV) repair has become the preferred operation for patients with mitral valvular disease. However, severe subvalvular deformity often precludes successful repair. Polytetrafluoroethylene (PTFE) suture has been used for chordal replacement in this group of patients, with encouraging early results.1
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Patients and Methods
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From March 1994 to December 1999, 30 patients underwent MV repair using PTFE suture for chordal replacement at Central Chest Hospital. One patient was lost to follow-up and excluded from the study. The remaining 14 males and 15 females ranged in age from 17 to 66 years (mean, 40.6 years). The majority (17 patients) had rheumatic disease, 5 had degenerative disease, 6 had infective endocarditis, and 1 had ischemic heart disease. Preoperative diagnoses included isolated mitral regurgitation (MR) in 13 patients, mixed mitral stenosis and MR (7), isolated mitral stenosis (5), combined MR and tricuspid regurgitation (3), and MR with ischemic heart disease (1). Preoperatively, 26 patients were in New York Heart Association (NYHA) functional class III and IV, and 3 were in class II. The mean preoperative NYHA functional class was 3.13.
A median sternotomy was performed in all patients and cardiopulmonary bypass was instituted with moderate hypothermia (28°C to 30°C). Cold blood cardioplegia was given intermittently either by antegrade, retrograde, or a combined route every 25 to 30 minutes. The MV was usually approached by a combined superior-transseptal incision. Warm blood terminal reperfusion was given prior to aortic declamping. The surgical findings were mostly of rheumatic pathology (Table 1
). Multiple surgical procedures were needed to accomplish MV repair in all cases; there was a mean of 5.5 surgical procedures per patient. Details of the operations and surgical procedures are depicted in Tables 2 and 3. Mean cardiopulmonary bypass and aortic crossclamp times were 155.3 and 120.5 minutes, respectively. The technique of chordal replace-ment using 5/0 double-arm PTFE suture (Gore-Tex; WL Gore, Flagstaff, AZ, USA) has been described previously.1 The average number of pairs of PTFE sutures per patient was 1.34. All patients underwent postoperative echo-cardiography at intervals during an average period of 12.4 months. Follow-up was conducted at outpatient clinics for 4 to 70 months (mean, 36.6 months) post-operatively.
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Results
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There was no hospital mortality; however, one patient died at 20 months postoperatively from chronic obstructive pulmonary disease. There was no reoperation or structural failure of the new PTFE chord during the period of this study. No thromboembolic or bleeding complication was noted. Of the surviving 28 patients, 17 were in NYHA functional class I, and 11 were in class II postoperatively. Echocardiography showed improvement in the left ventricular end-diastolic diameter from 57.25 mm before surgery to 52.3 mm postoperatively. Left ventricular end-systolic diameter decreased from 38.25 mm to 37.07 mm postoperatively. Preoperatively, 23 patients had significant MR (8 had +2, 5 had +3, and 10 had +4 degrees) with a mean of +3.1 degrees. In the postoperative period, 15 of these patients had no or trivial MR, 6 had +1 degree, and 2 had +2 degrees (mean, +0.43 degrees). No incidence of hemolytic anemia was seen in this study.
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Discussion
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Mitral valve repair has proven to be superior to MV replacement due to several advantages.2 However, severe pathology of the subvalvular apparatus often precludes successful MV repair. PTFE suture was introduced for chordal replacement in this group of patients, especially when there is no appropriate native chordae available, and it has been shown to be effective and durable in both experimental and clinical studies.3–5 Microscopic evaluation of the PTFE suture showed evidence of formation of new collagen and an endothelial layer, which is promising in terms of the durability and anticoagulation properties of this material.6 This suture has also been used in infants and children with good results.7,8 A recent study by Phillips and colleagues9 showed superior results of chordal replacement with PTFE over chordal shortening in the treatment of anterior mitral leaflet prolapse.
Our midterm results of chordal replacement with this suture are satisfactory and confirm our early findings.1 A precise surgical technique to achieve the correct length of the new chordae is crucial for a good outcome. This technique was particularly useful in our population of patients, many of whom had subvalvular deformities due to the rheumatic process, and no suitable native chordae were available. It was concluded that PTFE suture for chordal replacement in MV repair is safe and offers a stable repair with satisfactory midterm results. Its use should be encouraged to enhance the success rate of MV repair.
Presented at the 8th Annual Meeting of The Asian Society for Cardiovascular Surgery, Fukuoka, Japan, September 6–8, 2000.
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References
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Chotivatanapong T, Chaiseri P, Kasemsarn C, Sungkahapong V. Chordal replacement with expanded polytetrafluoroethylene suture: early results. Asian Cardiovasc Thorac Ann 1998;6:49–51.[Abstract/Free Full Text]
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Revuelta JM, Garcia-Rinaldi R, Gaite L, Val F, Garijo F. Generation of chordae tendineae with polytetra-fluoroethylene stents. Results of mitral valve chordal replacement in sheep. J Thorac Cardiovasc Surg 1989; 97:98–103.[Abstract]
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Eishi K, Kawazoe K, Nakano K, Kosakai Y, Sasako Y, Kobayashi J. Long-term results of artificial chordae implantation in patients with mitral valve prolapse. J Heart Valve Dis 1997;6:594–8.[Medline]
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David TE, Omran A, Armstrong S, Sun Z, Ivanov J. Long-term results of mitral valve repair for myxomatous disease with and without chordal replacement with expanded polytetrafluoroethylene sutures. J Thorac Cardiovasc Surg 1998;115:1279–83.[Abstract/Free Full Text]
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Minatoya K, Okabayashi H, Shimada I, Ohno N, Nishina T, Yokota T, et al. Pathologic aspects of polytetra-fluoroethylene sutures in human heart. Ann Thorac Surg 1996;61:883–7.[Abstract/Free Full Text]
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Matsumoto T, Kado H, Masuda M, Shiokawa Y, Fukae K, Morita S, et al. Clinical results of mitral valve repair by reconstructing artificial chordae tendineae in children. J Thorac Cardiovasc Surg 1999;118:94–8.[Abstract/Free Full Text]
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Phillips MR, Daly RC, Schaff HV, Dearani JA, Mullany CJ, Orszulak TA. Repair of anterior leaflet mitral valve prolapse: chordal replacement versus chordal shortening. Ann Thorac Surg 2000;69:25–9.[Abstract/Free Full Text]
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Abstract
Introduction
