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J Thorac Cardiovasc Surg 1997;114:1125-1127
© 1997 Mosby, Inc.

LETTERS TO THE EDITOR

Repair of anterior leaflet prolapse: Chordal transfer versus chordal shortening. Which is better?

P. Fundaró, M. Lemma, D. G. Di Mattia, C. Santoli

Dipartimento di Chirurgia Toracica e Cardiovasculaire
Ospedale Luigi Sacco
Via G. B. Grassi, 74
20157 Milano, Italy
12/8/84440

To the Editor:

We read with interest the paper recently published in the Journal by Smedira and associatesGo 1: "Repair of Anterior Leaflet Prolapse: Chordal Transfer Is Superior to Chordal Shortening." The authors compare the efficacy of the two techniques by analyzing the case histories of 108 patients with degenerative myxomatous mitral insufficiency and anterior leaflet prolapse. Chordal shortening was performed in 31 patients (29%) and chordal transfer in 77 (71%) patients. They conclude that "chordal transfer is superior to chordal shortening, providing a more predictable correction of mitral regurgitation and a lower incidence of reoperation. Reoperations after chordal shortening are a result of rupture of the previously shortened chordae."

We congratulate the authors for the originality and accuracy of their study. Nevertheless, we believe that the reported conclusions should be restricted to the chordal shortening technique used by the authors, which consists in "burying the chordae in a papillary muscle trench as described by Carpentier."

Since 1993, in 31 patients with degenerative myxomatous mitral regurgitation, we have repaired anterior leaflet prolapse caused by chordal elongation without chordal rupture by means of an original shortening technique of chordal plication at the level of the leaflet's free edge. This procedure, which takes other previously described techniques Go Go 2, 3 as a starting point, has already been published.Go 4 It requires two running sutures involving the chordal cusp junction of the prolapsing portion. These sutures include the free edge and the chordae for a variable length, depending on the degree of elongation, taking bites of 3 to 5 mm to strengthen and remodel the leaflet's free edge (Fig. 1). Only the rough zone must be included in the continuous suture, because bites involving the "body" leaflet could excessively warp the cusp. The procedure is usually completed by a posterior annuloplasty reinforced by a glutaraldehyde-tanned strip of autologous pericardium.Go 5 In our experience, a concomitant posterior leaflet resection was performed in 21 (67.7%) patients as a part of the repair procedure. We had no hospital deaths. Intraoperative transesophageal echocardiography demonstrated a successful valve repair in all the patients with correction of anterior leaflet prolapse and a fit leaflet coaptation at or below the annular plane Go(Fig. 2). Postrepair regurgitation was absent or trivial in 22 patients (70%) and mild in nine (30%). One patient (3.2%) required early reoperation for recurrent mitral regurgitation resulting from a recurring anterior leaflet prolapse. Intraoperatively, it was observed that the remodeling running suture had broken at its midportion, probably cut by the needle itself. The same technique was used again successfully to correct the anterior leaflet prolapse. The patient had an uneventful recovery. Follow-up time is 100% complete at an average of 16.8 months (range 1 to 41 months). A total of 43.4 patient-years are available for analysis. The patient who underwent a second mitral valve repair required mitral valve replacement 2 months later for hemolytic anemia resulting from an unchanged moderate high-speed mitral regurgitation.



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  		Fig. 1. Technique of chordal suture plication and free edge remodeling. Inset: Upward arrow shows plication of elongated chordae; downward arrow shows repair of interchordal prolapse.

 



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  		Fig. 2. Intraoperative transesophageal echocardiography. A, Prerepair evidence of prominent anterior leaflet (AL) prolapse associated with posterior leaflet (PL) eversion caused by chordal rupture. B, After chordal suture plication and free edge remodeling mobility of anterior leaflet is normalized. A posterior leaflet quadrangular resection was also performed. Arrowhead shows large coaptation of the leaflets.

 
In their article Smedira and associates report that after a follow-up of 16 ± 19 months (range 2 to 62 months) 11 patients, four after chordal transfer and seven after chordal shortening, required reoperation. They note that "six of the seven shortened chordae had ruptured at the site of insertion into the papillary muscle." They argue that chordal ruptures may be related to the fact that elongated chordae are by definition structurally weakened and consequently liable to rupture and that chordal shortening changed their stress degree. The authors' assumptions have a sound basis. Nevertheless, inasmuch as six of seven shortened chordae had ruptured at the same level, we are afraid that something is not working properly in their chordal shortening technique. We agree that myxomatous valves have weakened chordae, but we believe that this does not determine postrepair rupture. We consider an unevenly distributed chordal stress after shortening as being more relevant. As a matter of fact, it must be remembered that elongated and weakened posterior leaflet chordae are also used in transfer techniques, giving durable results in repair of anterior leaflet prolapse. This suggests that even if structurally weakened, transferred chordae usually do not break, probably because they work with a more physiologic amount of tension. As far as the authors' technique is concerned, an excessive amount of tension on a single chorda after shortening could be seen as being the cause of the rupture. It is also possible that the papillary muscle trench could have a negative effect on blood perfusion leading to chordal rupture at its papillary insertion. Moreover, the looping suture could itself be responsible for damage to the chorda.

With our shortening technique, chordal stress distribution is probably more similar to chordal transfer. The two running sutures include several primary and secondary chordae, facilitating a more even distribution of tension among many chordae. Simultaneously, it makes it possible to correct any interchordal prolapse (redundancy between adjacent chordal insertions) resulting in a uniform free edge remodeling and a better leaflet coaptation, which seems to reduce the tension on the chordae.Go 6 Finally, our technique leaves the papillary muscle intact.

Our experience with the technique of chordal suture plication and free edge remodeling in patients with anterior leaflet prolapse without chordal rupture suggests that chordal shortening can be as effective as chordal transfer at midterm. This technique is more straightforward than other shortening techniques and makes it possible to keep the posterior leaflet intact in the absence of prolapse, as in 10 (32.3%) of our 31 patients. A larger number of patients, however, and a longer follow-up are required to confirm our results.

[Response declined]

References

  1. Smedira NG, Selman R, Cosgrove DM, McCarthy PM, Lytle BW, Taylor PC, et al. Repair of anterior leaflet prolapse: chordal transfer is superior to chordal shortening. J Thorac Cardiovasc Surg 1996;112:287-92. [Abstract/Free Full Text]
  2. Frater RWM. Mitral valvuloplasty. In: Roberts AJ, Conti CR, editors. Current surgery of the heart. Philadelphia: Lippincott; 1987. p. 62-77.
  3. Kumar AS, Bhan A, Kumar RW, Shrivastava S, Sood AK, Gopinath M. Cusp-level chordal shortening for rheumatic mitral regurgitation: early results. Tex Heart Inst J 1992;19:47-50. [Medline]
  4. Fundaró P, Di Mattia DG, Salati M, Santoli C. Free edge suture plication and remodeling: a technique for anterior mitral leaflet prolapse repair. Ann Thorac Surg 1997;63:1186-8. [Abstract/Free Full Text]
  5. Salati M, Scrofani R, Fundaró P, Cialfi A, Santoli C. Correction of anterior mitral prolapse: results of chordal transposition. J Thorac Cardiovasc Surg 1992;104:1268-73. [Abstract]
  6. Reimink MS, Kunzelman KS, Verrier ED, Cochran RP. Artificial chordae tendineae and stresses in the mitral valve: a finite element analysis. ASAIO J 1995;41(Suppl:Jan-March 1995):26.



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