Early outcomes of totally endoscopic mitral valve repair with artificial chordae implantation_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

ZHU Ren ,  HUANG Huanlei , LIU Jian , GUO Huiming , XIE Bin , KE Yingjie , ZENG Qingshi , LU Cong

Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, P.R.China;

Corresponding author：

HUANG Huanlei, Email: hhuanlei@hotmail.com

Keywords：

Minimally invasive surgery; mitral valvuloplasty; artificial chordae

DOI：

10.7507/1007-4848.201610016

Video：

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Objective To evaluate the outcomes and summarize the clinical experience of totally endoscopic mitral valve repair with artificial chordae implantation. Methods From May 2013 to June 2016, 71 patients with mitral valve insufficiency were admitted to our hospital who underwent totally endoscopic mitral valve repair with artificial chordae implantation. There were 47 males and 24 females with the age of 46.0±14.4 years ranging from 13-78 years. The pathogenesis included degenerative valvular diseases in 63 patients, congenital valvular diseases in 4, infectious endocarditis in 2, rheumatic disease in 1 and cardiomyopathy in 1. Prolapse of anterior, posterior, or both leaflets was present in 26 (36.6%), 19 (26.8%), and 25 (35.2%) patients, respectively; one patient (1.4%) presented valve annulus enlargement and thirteen were associated with commissure lesion. The mitral regurgitation area ranged from 4.2 to 26.3 cm² (mean, 12.2±5.6 cm²). All the procedures were performed by total endoscopy under cardiac arrest. 5-0 Gore-tex sutures were used as the material of artificial chordae which was implanted one by one. Results There was no in-hospital death. One patient was transferred to mitral valve replacement, and one median sternotomy due to bleeding. The mean cardiopulmonary bypass time was 156.0±31.6 min and aortic cross-clamp time 110.0±20.1 min. We finally had 39 isolated mitral valve repair, 28 mitral valve repair combined tricuspid valve repair, 3 mitral valve repair combined atrial septal defect closure, and 1 mitral valve repair combined correction of partial anomalous pulmonary vein connection. Each patient was implanted artificial chordae of 2.5±1.7 (ranging from 1 to 7), and 65 patients received mitral annulus (full ring). The intraoperative transoesophageal echocardiography found no mitral regurgitation in 44 patients, the area of mitral regurgitation was 0-2 cm² in 24, and 3 patients with mitral regurgitation>2 cm² experienced serious systolic anterior motion. Of the 3 patients with systolic anterior motion (SAM), one transferred to mitral valve replacement, one underwent mitral re-repair, and one took conservative treatment. The mean follow-up was 12.7±10.5 months (range: 1 to 36 months), while 2 patients were lost to follow up with the follow-up rate of 97.2%. Recurrent severe regurgitation occured in 3 patients, moderate in 5, mild or trivial in 27 and no regurgitation in 36. During the follow-up, 1 patient died of myocardiopathy-induced heart failure post discharge, 1 suffered from cerebral infarction, and no patient underwent reoperation. Conclusion The totally endoscopic surgical treatment of mitral valvuloplasty with artificial chordae is reliable for patients with mitral valve prolapse, which provides favorable clinical efficacy and outcomes. The difficulty lies in how to determine the appropriate length of the chordae and keep the stability of length.

Citation： ZHU Ren, HUANG Huanlei, LIU Jian, GUO Huiming, XIE Bin, KE Yingjie, ZENG Qingshi, LU Cong. Early outcomes of totally endoscopic mitral valve repair with artificial chordae implantation. Chinese Journal of Clinical Thoracic and Cardiovascular Surgery, 2017, 24(10): 787-790. doi: 10.7507/1007-4848.201610016 Copy

1.	Salvador L, Mirone S, Bianchini R, 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.
2.	Zussa C, Polesel E, Rocco F, et al. Artificial chordae in the treatment of anterior mitral leaflet pathology. Cardiovasc Surg, 1997, 5(1):125-128.
3.	Kobayashi J, Sasako Y, Bando K, et al. Ten-year experience of chordal replacement with expanded polytetrafluoroethylene in mitral valve repair. Circulation, 2000, 102(19 Suppl 3): Ⅲ30-Ⅲ34.
4.	Bergsland J, Mujanovic E, Elle O, et al. Minimally invasive repair of the mitral valve: Technological and clinical developments. Minim Invasive Ther Allied Technol, 2011, 20(2):72-77.
5.	Lange R, Voss B, Kehl V, et al. Right minithoracotomy versus full sternotomy for mitral valve repair: a propensity matched comparison. Ann Thorac Surg, 2017, 103(2): 573-579..
6.	Holzhey DM, Seeburger J, Misfeld M, et al. Learning minimally invasive mitral valve surgery a cumulative sum sequential probability analysis of 3895 operations from a single high-volume center. Circulation, 2013, 128(5): 483-491.
7.	Iribarne A, Easterwood R, Russo MJ, et al. Comparative effectiveness of minimally invasive versus traditional sternotomy mitral valve surgery in elderly patients. J Thorac Cardiovasc Surg, 2012, 143(4-Sup): 86-90.
8.	Rogers CA, Reeves BC, Caputo M, et al. Control chart methods for monitoring cardiac surgical performance and their interpretation. J Thorac Cardiovasc Surg, 2004, 128(6): 811-819.
9.	Murzi M, Cerillo AG, Miceli A, et al. Antegrade and retrograde arterial perfusion strategy in minimally invasive mitral-valve surgery: a propensity score analysis on 1280 patients. Eur J Cardiothorac Surg, 2013, 43(6): 167-172.
10.	Yozu R, Okamoto K, Kudo M, et al. New innovative instruments facilitate both direct-vision and endoscopic-assisted mini-mitral valve surgery. J Thorac Cardiovasc Surg, 2012, 143(4 Suppl): S82-S85.
11.	Glauber M, Ferrarini M, Miceli A. Minimally invasive mitral valve repair using a semi-rigid annuloplasty ring with a new chordal sizing system: the Memo3D ReChord. Ann Cardiothorac Surg, 2015, 4(3): 298-300.
12.	DoiA, Iida H, Sunazawa T. Intracardiac calipers for artificial chordae replacement in mitral valve repair. Ann Thorac Surg, 2009, 87(1): 326-328.
13.	Huang HL, Xie XJ, Fei HW. Real-time three-dimensional transesophageal echocardiography to predict artificial chordae length for mitral valve repair. J Cardiothorac Surg, 2013, 8: 137.
14.	Fattouch K, Bianco G, Sbraga F, et al. Simple, safe and easy technique to ensure the correct length of artificial chordae in mitral valve repair. Ann Thorac Surg, 2007, 83(5): 1902-1903.
15.	Matsui Y, Kubota S, Sugiki H, et al. Measured tube technique for ensuring the correct length of slippery artificial chordae in mitral valvuloplasty. Ann Thorac Surg, 2011, 92(3): 1132-1134.
16.	Ibrahim M, Rao C, Athanasiou T. Artificial chordae for degenerative mitral valve disease: critical analysis of current techniques. Interact Cardiovasc Thorac Surg, 2012, 15(6):1019-1032.
17.	Hata H,Fujita T,Shimahara Y, et al. A 25-year study of chordal replacement with expanded polytetrafluoroethylene in mitral valve repair. Interact Cardiovasc Thorac Surg, 2015, 20(4): 463-468.
18.	Galloway AC, Schwarts CF, Ribakove GH, et al. A decade of minimally invasive mitral repair: long-term outcomes. Ann Thorac Surg, 2009, 88(4): 1180-1184.
19.	Okamoto K, Kudo M, Shimizu H. Mitral valve repair with minimally invasive cardiac surgery approach as routine practice. Nihon Geka Gakkai Zasshi, 2016, 117(2): 124-129.
20.	Iribarne A, Russo MJ, Easterwood R, et al. Minimally invasive versus sternotomy approach for mitral valve surgery: A propensity analysis. Ann Thorac Surg, 2010, 90(5): 1471-1477.

1. Salvador L, Mirone S, Bianchini R, 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.
2. Zussa C, Polesel E, Rocco F, et al. Artificial chordae in the treatment of anterior mitral leaflet pathology. Cardiovasc Surg, 1997, 5(1):125-128.
3. Kobayashi J, Sasako Y, Bando K, et al. Ten-year experience of chordal replacement with expanded polytetrafluoroethylene in mitral valve repair. Circulation, 2000, 102(19 Suppl 3): Ⅲ30-Ⅲ34.
4. Bergsland J, Mujanovic E, Elle O, et al. Minimally invasive repair of the mitral valve: Technological and clinical developments. Minim Invasive Ther Allied Technol, 2011, 20(2):72-77.
5. Lange R, Voss B, Kehl V, et al. Right minithoracotomy versus full sternotomy for mitral valve repair: a propensity matched comparison. Ann Thorac Surg, 2017, 103(2): 573-579..
6. Holzhey DM, Seeburger J, Misfeld M, et al. Learning minimally invasive mitral valve surgery a cumulative sum sequential probability analysis of 3895 operations from a single high-volume center. Circulation, 2013, 128(5): 483-491.
7. Iribarne A, Easterwood R, Russo MJ, et al. Comparative effectiveness of minimally invasive versus traditional sternotomy mitral valve surgery in elderly patients. J Thorac Cardiovasc Surg, 2012, 143(4-Sup): 86-90.
8. Rogers CA, Reeves BC, Caputo M, et al. Control chart methods for monitoring cardiac surgical performance and their interpretation. J Thorac Cardiovasc Surg, 2004, 128(6): 811-819.
9. Murzi M, Cerillo AG, Miceli A, et al. Antegrade and retrograde arterial perfusion strategy in minimally invasive mitral-valve surgery: a propensity score analysis on 1280 patients. Eur J Cardiothorac Surg, 2013, 43(6): 167-172.
10. Yozu R, Okamoto K, Kudo M, et al. New innovative instruments facilitate both direct-vision and endoscopic-assisted mini-mitral valve surgery. J Thorac Cardiovasc Surg, 2012, 143(4 Suppl): S82-S85.
11. Glauber M, Ferrarini M, Miceli A. Minimally invasive mitral valve repair using a semi-rigid annuloplasty ring with a new chordal sizing system: the Memo3D ReChord. Ann Cardiothorac Surg, 2015, 4(3): 298-300.
12. DoiA, Iida H, Sunazawa T. Intracardiac calipers for artificial chordae replacement in mitral valve repair. Ann Thorac Surg, 2009, 87(1): 326-328.
13. Huang HL, Xie XJ, Fei HW. Real-time three-dimensional transesophageal echocardiography to predict artificial chordae length for mitral valve repair. J Cardiothorac Surg, 2013, 8: 137.
14. Fattouch K, Bianco G, Sbraga F, et al. Simple, safe and easy technique to ensure the correct length of artificial chordae in mitral valve repair. Ann Thorac Surg, 2007, 83(5): 1902-1903.
15. Matsui Y, Kubota S, Sugiki H, et al. Measured tube technique for ensuring the correct length of slippery artificial chordae in mitral valvuloplasty. Ann Thorac Surg, 2011, 92(3): 1132-1134.
16. Ibrahim M, Rao C, Athanasiou T. Artificial chordae for degenerative mitral valve disease: critical analysis of current techniques. Interact Cardiovasc Thorac Surg, 2012, 15(6):1019-1032.
17. Hata H,Fujita T,Shimahara Y, et al. A 25-year study of chordal replacement with expanded polytetrafluoroethylene in mitral valve repair. Interact Cardiovasc Thorac Surg, 2015, 20(4): 463-468.
18. Galloway AC, Schwarts CF, Ribakove GH, et al. A decade of minimally invasive mitral repair: long-term outcomes. Ann Thorac Surg, 2009, 88(4): 1180-1184.
19. Okamoto K, Kudo M, Shimizu H. Mitral valve repair with minimally invasive cardiac surgery approach as routine practice. Nihon Geka Gakkai Zasshi, 2016, 117(2): 124-129.
20. Iribarne A, Russo MJ, Easterwood R, et al. Minimally invasive versus sternotomy approach for mitral valve surgery: A propensity analysis. Ann Thorac Surg, 2010, 90(5): 1471-1477.

Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Early outcomes of totally endoscopic mitral valve repair with artificial chordae implantation

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