Clinical Analysis of Patients Undergoing Mitral Valvuloplasty for Anterior Mitral Leaflet Prolapse with Looped　Artificial Chordae_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

SUN Guanglong , CAO Xiangrong , ZHANG Jianqun.

Department of Cardiac Surgery，Beijing Anzhen Hospital，Capital Medical University，Beijing 100029，P. R. China;

Corresponding author：

Keywords：

Anterior mitral leaflet; Mitral valve prolapse; Mitra1 valvuloplasty; Loop; Artificial chordae

DOI：

10.7507/1007-4848.20130130

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Objective To summarize surgical techniques，advantages and clinical outcomes of mitral valvuloplasty for anterior mitral leaflet prolapse with looped artificial chordae. Methods Clinical data of 13 patients with anteriormitral leaflet prolapse and severe mitral regurgitation （MR） who underwent mitral valvuloplasty with looped artificial chordaefrom January 2009 to December 2011 in Beijing Anzhen Hospital were retrospectively analyzed. There were 8 male and 5 female patients with their age of 21-61 （39.5±12.9） years. There were 10 patients with anterior mitral leaflet chordal rupture and 3 patients with anterior mitral leaflet elongation. Preoperative left ventricular end-diastolic diameter （LVEDD） was 52-65 （58.3±1.7） mm，and left ventricular ejection fraction （LVEF） was 53%-65% （58.8%±2.8%）. All the patients underwent mitral valvuloplasty. We measured the neighboring normal chordae with a caliper for reference and constructed the artificial chordal loops on the caliper with expended polytetrafluoroethylene（ePTFE） CV4 Gore-Tex suture lines. Three to five loops were made and fixed to the papillary muscle with a Gore-Tex suture line and the free edge of the prolapsedanterior mitral leaflet with another Gore-Tex suture line，with the intervals between the loops of 5 mm. Left ventricular watertesting was performed to evaluate MR status，annuloplasty ring implantation or “edge to edge” technique was used if nece-ssary，and left ventricular water testing was performed again to confirm satisfactory closure of the mitral valve. Patientsreceived re-warming on cardiopulmonary bypass and the heart incision was closed. The effect of mitral annuloplasty was alsoassessed by transesophageal echocardiography （TEE） after heart rebeating. Warfarin anticoagulation was routinely used for 3 months after discharge. Results There was no perioperative death in this group. Twelve patients received satisfactory outcomes after 1-stage mitral valvuloplasty with looped artificial chordae and annuloplasty ring implantation. One patient didn’t receive satisfactory outcomes in the left ventricular water testing after mitral valvuloplasty with looped artificial chordae，but satisfactory outcome was achieve after “edge to edge” technique was used，and annuloplasty ring was not used for this patient. Postoperative echocardiography showed trivial to mild MR in all the patients，their LVEDD was significantly reducedthan preoperative LVEDD （47.5±2.1 mm vs. 58.3±1.7 mm，P＜0.05），and there was no statistical difference between postoperative and preoperative LVEF（58.5%±2.6% vs. 58.8%±2.8%，P＞0.05）. All the patients were followed up for 3-36 （19.5±3.7） months. Echocardiography showed mild MR in 4 patients and none or trivial MR in 9 patients during follow-up.Conclusion Mitral valvuloplasty with looped artificial chordae is an effective surgical technique for the treatment of anterior mitral leaflet prolapse with satisfactory clinical outcomes，and this technique is also easy to perform.

Citation： SUN Guanglong,CAO Xiangrong,ZHANG Jianqun.. Clinical Analysis of Patients Undergoing Mitral Valvuloplasty for Anterior Mitral Leaflet Prolapse with Looped　Artificial Chordae. Chinese Journal of Clinical Thoracic and Cardiovascular Surgery, 2013, 20(4): 420-424. doi: 10.7507/1007-4848.20130130 Copy

1.	Gillinov AM， Blackstone EH， Nowicki E， et al. Valve repair versusvalve replacement for degenerative mitral valve disease. J Thorac Cardiovasc Surg， 2008， 135 （4）：885-893.
2.	９　Matsui Y， Kubota S， Sugiki H， et al. Measured tube technique for ensuring the correct length of slippery artificial chordae in mitral valvu-loplasty. Ann Thorac Surg， 2011， 92 （3）：1132-1134.
3.	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 （6）：2166-2168.
4.	Kouchoukos NT， Blackstone EH， Doty DB， et al， Chief Editor. Cardiac surgery. 3rd. New York：Churchill Livingstone， 2003. 483-553.
5.	Gammie JS， Zhao Y， Peterson ED， et al. J. Maxwell ChamberlainMemorial Paper for adult cardiac surgery. Less-invasive mitral valve operations：trends and outcomes from the Society of Thoracic SurgeonsAdult Cardiac Surgery Database. Ann Thorac Surg， 2010， 90 （5）：1401-1410.
6.	David TE， Bos J， Rakowski H. Mitral valve repair by replacement of Chordae tendineae with polytetrafluoroethylene sutures. J Thorac Cardiovasc Surg， 1991， 101 （3）：495-501.
7.	Zussa C， Frater RW， Polesel E， et al. Artificial mitral valve chordae：experimental and clinical experience. Ann Thorac Surg， 1990， 50 （3）：367-373.
8.	Cochran RP， Kunzelman KS. Comparison of voscoelastic properties of suture versus porcine mitral valve chordae tendineae. J Card Surg， 1991， 6 （4）：508-513.
9.	Loris S， Salvatore M， Roberto B， et al. A 20-year experience with mitral valve repair with artificial chordae in 608 patients. J Thorac Cardiovasc Surg， 2008， 135 （6）：1280-1287.
10.	Phillips MR， Daly RC， Schaff HV， et al. Repair of anterior leaflet mitral valve prolapse：chordal replacement versus chordal shortening. Ann Thorac Surg， 2000， 69 （1）：25-29.
11.	陈伟，张健群，甘辉立．腱索折叠与腱索转移矫治二尖瓣前瓣脱垂的比较分析．中国胸心血管外科临床杂志， 2010， 17 （1）：26-31．.
12.	李继勇，张健群，张富恩，等．后叶腱索转移治疗二尖瓣前叶脱垂．中国胸心血管外科临床杂志， 2009， 16 （3）：170-173．.
13.	Smith JM， Stein H. Endoscopic placement of multiple artificial chordaewith robotic assistance and nitinol clip fixation. J Thorac Cardiovasc Surg， 2008， 135 （3）：610-614.
14.	Rodriguez E， Nifong LW， Chu MW， et al. Robotic mitral valve repair for anterior leaflet and bileaflet prolapse. Ann Thorac Surg， 2008， 85 （2）：438-444.
15.	Maselli D， Ficarra E， Weltert L， et al. A method to avoid knot-tying in artificial chordae implantation for mitral valve repair. J Heart Valve Dis， 2010， 19 （2）：249-253.
16.	Iida H， Sunazawa T， Doi A， et al. A device for ensuring the neochordae replacement in mitral valve repair. Ann Thorac Surg， 2010， 90 （6）：2071-2072.
17.	Garcia-Fuster R， Gil O， Vazquez A， et al. The folding leaflet：a simple method for neochordal repair. Ann Thorac Surg， 2010， 89 （5）：1682-1684.
18.	Ruyra-Baliarda X. Preliminary experience with the no prolapse system.A new device for ensuring the proper length of artificial chordae in mitral valve repair. Interact Cardiovasc Thorac Surg， 2010， 10 （2）：165-167.
19.	Cagli K. A simple method of making artificial chordal loops for mitralvalve repair. Ann Thorac Surg， 2010， 89 （2）：e12-e14.
20.	Chang JP， Kao CL. Slit stent technique for ensuring the correct length of artificial chordae in mitral repair. J Card Surg， 2011， 26 （3）：259-260.
21.	Kudo M， Yuzu R， Kokaji K， et al. Feasibility of mitral valve repair using the loop technique. Ann Thorac Cardiovasc Surg， 2007， 13 （1）：21-26.
22.	Seeburger J， Kuntze T， Mohr F. Gore-Tex chordoplasty in degenerative mitral valve repair. Semin Thorac Cardiovasc Surg， 2007， 19 （2）：111-115.
23.	Kuntze T， Borger MA， Falk V， et al. Early and mid-term results of mitral valve repair using premeasured Gore-Tex loops （’loop technique’）. Eur J Cardiothorac Surg， 2008 ， 33 （4）：566-572.
24.	Bergsland J， Mujanovic E， Elle OJ， et al. Minimally invasive repair of the mitral valve：technological and clinical developments. Minim Invasive Ther Allied Technol， 2011， 20 （2）：72-77.

1. 　Gillinov AM， Blackstone EH， Nowicki E， et al. Valve repair versusvalve replacement for degenerative mitral valve disease. J Thorac Cardiovasc Surg， 2008， 135 （4）：885-893.
2. ９　Matsui Y， Kubota S， Sugiki H， et al. Measured tube technique for ensuring the correct length of slippery artificial chordae in mitral valvu-loplasty. Ann Thorac Surg， 2011， 92 （3）：1132-1134.
3. 　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 （6）：2166-2168.
4. 　Kouchoukos NT， Blackstone EH， Doty DB， et al， Chief Editor. Cardiac surgery. 3rd. New York：Churchill Livingstone， 2003. 483-553.
5. 　Gammie JS， Zhao Y， Peterson ED， et al. J. Maxwell ChamberlainMemorial Paper for adult cardiac surgery. Less-invasive mitral valve operations：trends and outcomes from the Society of Thoracic SurgeonsAdult Cardiac Surgery Database. Ann Thorac Surg， 2010， 90 （5）：1401-1410.
6. 　David TE， Bos J， Rakowski H. Mitral valve repair by replacement of Chordae tendineae with polytetrafluoroethylene sutures. J Thorac Cardiovasc Surg， 1991， 101 （3）：495-501.
7. 　Zussa C， Frater RW， Polesel E， et al. Artificial mitral valve chordae：experimental and clinical experience. Ann Thorac Surg， 1990， 50 （3）：367-373.
8. 　Cochran RP， Kunzelman KS. Comparison of voscoelastic properties of suture versus porcine mitral valve chordae tendineae. J Card Surg， 1991， 6 （4）：508-513.
9. 　Loris S， Salvatore M， Roberto B， et al. A 20-year experience with mitral valve repair with artificial chordae in 608 patients. J Thorac Cardiovasc Surg， 2008， 135 （6）：1280-1287.
10. 　Phillips MR， Daly RC， Schaff HV， et al. Repair of anterior leaflet mitral valve prolapse：chordal replacement versus chordal shortening. Ann Thorac Surg， 2000， 69 （1）：25-29.
11. 　陈伟，张健群，甘辉立．腱索折叠与腱索转移矫治二尖瓣前瓣脱垂的比较分析．中国胸心血管外科临床杂志， 2010， 17 （1）：26-31．.
12. 　李继勇，张健群，张富恩，等．后叶腱索转移治疗二尖瓣前叶脱垂．中国胸心血管外科临床杂志， 2009， 16 （3）：170-173．.
13. 　Smith JM， Stein H. Endoscopic placement of multiple artificial chordaewith robotic assistance and nitinol clip fixation. J Thorac Cardiovasc Surg， 2008， 135 （3）：610-614.
14. 　Rodriguez E， Nifong LW， Chu MW， et al. Robotic mitral valve repair for anterior leaflet and bileaflet prolapse. Ann Thorac Surg， 2008， 85 （2）：438-444.
15. 　Maselli D， Ficarra E， Weltert L， et al. A method to avoid knot-tying in artificial chordae implantation for mitral valve repair. J Heart Valve Dis， 2010， 19 （2）：249-253.
16. 　Iida H， Sunazawa T， Doi A， et al. A device for ensuring the neochordae replacement in mitral valve repair. Ann Thorac Surg， 2010， 90 （6）：2071-2072.
17. 　Garcia-Fuster R， Gil O， Vazquez A， et al. The folding leaflet：a simple method for neochordal repair. Ann Thorac Surg， 2010， 89 （5）：1682-1684.
18. 　Ruyra-Baliarda X. Preliminary experience with the no prolapse system.A new device for ensuring the proper length of artificial chordae in mitral valve repair. Interact Cardiovasc Thorac Surg， 2010， 10 （2）：165-167.
19. 　Cagli K. A simple method of making artificial chordal loops for mitralvalve repair. Ann Thorac Surg， 2010， 89 （2）：e12-e14.
20. 　Chang JP， Kao CL. Slit stent technique for ensuring the correct length of artificial chordae in mitral repair. J Card Surg， 2011， 26 （3）：259-260.
21. 　Kudo M， Yuzu R， Kokaji K， et al. Feasibility of mitral valve repair using the loop technique. Ann Thorac Cardiovasc Surg， 2007， 13 （1）：21-26.
22. 　Seeburger J， Kuntze T， Mohr F. Gore-Tex chordoplasty in degenerative mitral valve repair. Semin Thorac Cardiovasc Surg， 2007， 19 （2）：111-115.
23. 　Kuntze T， Borger MA， Falk V， et al. Early and mid-term results of mitral valve repair using premeasured Gore-Tex loops （’loop technique’）. Eur J Cardiothorac Surg， 2008 ， 33 （4）：566-572.
24. 　Bergsland J， Mujanovic E， Elle OJ， et al. Minimally invasive repair of the mitral valve：technological and clinical developments. Minim Invasive Ther Allied Technol， 2011， 20 （2）：72-77.

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Clinical Analysis of Patients Undergoing Mitral Valvuloplasty for Anterior Mitral Leaflet Prolapse with Looped　Artificial Chordae

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Clinical Analysis of Patients Undergoing Mitral Valvuloplasty for Anterior Mitral Leaflet Prolapse with Looped　Artificial Chordae