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The Journal of Thoracic and Cardiovascular Surgery, Vol 95, 969-979, Copyright © 1988 by The American Association for Thoracic Surgery and The Western Thoracic Surgical Association
GE Sarris, PD Cahill, DE Hansen, GC Derby and DC Miller
Clinical studies suggest that chorda-sparing mitral valve replacement
techniques are associated with superior postoperative outcome, and several
animal experiments have shown that disruption of the mitral subvalvular
apparatus is followed by deterioration of left ventricular systolic
function. One essential element, however, underlying the importance of
chordal integrity for left ventricular function remains unproved: All
investigators heretofore have been unable to demonstrate that left
ventricular systolic performance can be restored by chordal reattachment
after disruption of annular-papillary continuity. Therefore, we studied the
effects of chordal detachment and subsequent chordal reattachment on left
ventricular systolic performance using an in situ, isovolumic heart
preparation in 10 halothane-anesthetized swine. The slope and left
ventricular volume intercept of the isovolumic peak pressure-volume
relationship were measured to assess global left ventricular systolic
performance independent of load. Coronary perfusion pressure was maintained
constant (95 +/- 6 mm Hg [+/- standard deviation]), and heart rates were in
the physiologic range (133 +/- 26 min-1). Slope changed significantly
(repeated measures analysis of variance, p = 0.0002), decreasing by 29%
(from 4.74 +/- 0.94 to 3.37 +/- 0.87 mm Hg/ml, p less than 0.001) after
chordal detachment and then returning to baseline (6.05 +/- 2.38 mm Hg/ml,
p = 0.001) after chordal reattachment. Slope after chordal reattachment was
not significantly different from the baseline value (p = 0.074). Volume
intercept did not change significantly (p = 0.44) at any time. We conclude
that the acute decrease in left ventricular contractility associated with
surgical interruption of annular-ventricular continuity can, in fact, be
reversed by chordal reattachment in this experimental model (isovolumically
contracting normal porcine hearts). These data provide concrete
confirmation of the concept of valvular-ventricular interaction; if these
findings can be corroborated in the dilated, human left ventricle, such
would strongly support efforts to preserve the mitral chordae tendineae
during clinical mitral valve replacement to optimize postoperative left
ventricular function.
ARTICLES
Restoration of left ventricular systolic performance after reattachment of the mitral chordae tendineae. The importance of valvular-ventricular interaction
Department of Cardiovascular Surgery, Stanford University Medical Center, CA 94305.
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